| Insurance Type: |
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| Business Name: |
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| Contact Name: |
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| E-Mail Address: |
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| Phone Number: |
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| Fax Number: |
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| Address: |
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| City: |
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| Zip: |
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| FEIN or SSN: |
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| Business Entity: |
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| Years In Business: |
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| Years Experience: |
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| Business
Classification |
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| Type of Restaurant: |
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| Seating Available? |
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| Table Service? |
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| Dance Floor? |
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| Live Entertainment? |
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| Catering? |
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| Deliveries? |
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| Alcohol Receipts? |
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Liquor: |
% |
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Beer/Wine: |
% |
| Desire Liquor Liability? |
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| Happy Hour? |
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| Full-Time Employees: |
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| Part-Time Employees: |
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| Bouncers or Doormen? |
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| Liability
Section |
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| Desired Effective Date: |
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| Desired Coverage Limits: |
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| Est. Annual Receipts: |
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| Est. Annual Payroll: |
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| Property Ownership: |
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| Year Built: |
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| Total Square Footage: |
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| Property
Section |
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| Construction Type: |
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| Number of Stories: |
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| Burglar Alarm Type: |
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| Fire Alarm Type: |
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| Fire Sprinklers: |
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| If Desired
Coverage |
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| Building(s) Value ($): |
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| Bus Pers Property ($): |
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| Bus Income (include EE) ($) |
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| Current
Policy: |
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| Current Insurance Co.: |
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| Expiring Premium ($): |
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| Years Without Lapse: |
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| Claims in Last 3 Years: |
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| Description
of Operations:
Please include a detailed description of business
operations. A brief description will slow down the quoting process and require additional
input from you.
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