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Restaurant Information
Contact Information
Corporation Name:*
D.B.A./ restaurant name:
Primary Contact:*
Primary Contact - Phone Number*
E-mail Address
Address of Restaurant:
City
State
Zip
Restaurant Information
Briefly Describe the Restaurant:
Approximate annual receipts for food sales:
Approximate annual receipts for alcohol sales:
Do you have a deep fryer?
Yes
No
Do you have entertainment?
Yes
No
If yes, what kind and how frequent?
Do you have a dance floor?
Yes
No
Do you have security?
Yes
No
How many locations do you have?
Insurance Coverage Information
What limits of General Liability would you like?
1 million per occurance/2 million aggregate
500,000/1 million
Other
What limit of liquor liability would you like?
100,000
300,000
500,000
500,000/1 million
Do you currently have insurance coverage?
Yes
No
If Yes, what is the expiration date of your current policy?
If yes, what is the name of your current company?
If yes what is the current annual amount that you are paying?
Have you had any claims in the last three years?
Yes
No
Property information
If you would like coverage on the building please list amount needed:
What amount of business personal property (contents) would you like?
0
10,000
25,000
50,000
75,000
100,000
125,000
150,000
175,000
200,000
250,000
350,000
500,000
750,000
Sq ft of building:
Type of construction:
Concrete block
Frame
Other
Type of roof:
Flat
Metal
Standard Shingle
Do you have a central station alarm?
Yes
No
Workers Compensation
Would you like a quote for workers compensation?
Yes
No
If yes, what is the payroll for the cooking staff?
If yes, what is the payroll for the wait staff?
Other Coverages
Would you like a quote for any of the following insurance?
Personal Auto
Group Health Insurance
Business Auto
Individual Life Insurance
Homeowners
Group Life Insurance
Commercial Property
Umbrella/ Excess Liability
Comments
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