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Restaurant / Bar Quote Application

Restaurant / Bar Quote Application
* Required Information

Full Name:*

E-mail Address:*

Daytime Phone:*

MAILING ADDRESS

Street:

City:

State:

Zipcode:*

Fax:

How would you like to be contacted?

Your Insurance/Financial needs:

Name of Business:

DBA:

RESTAURANT / BAR / TAVERN ADDRESS (if different from above)

Street:

City:

State:

Zip:

TYPE OF ESTABLISHMENT

	Restaurant		Diner
	Tavern / Bar		24 Hr. Diner
	Night Club		Hotel/Motel
	Pizza Parlor		Dinner House
	Country Club		Banquet Hall
	OTHER > > >

OPERATION INFORMATION

Entertainment

Liquor

Number of years in Restaurant Business:
Number of years at Present Location:
Number of years as Owner:
Is Owner/Mng on premises at all times:
Total Number of Employees (Full-time/Pt-Time):
Seating Capacity:

BUILDING INFORMATION:

Frame?
Fire Resistive?
Brick?

Sprinkler Alarm?
Central Station?
Building Owner?

Building Value:

Personal Property (contents):

FINANCIAL INFORMATION:

Annual Food Sales:

Annual Liquor Sales:

CURRENT INSURANCE INFORMATION:

Current Insurer:

Business Income Limit :

Policy Expiration Date:

Current Premium:

Losses/Claims within last 5 years.
Please Describe:

Thank you for completing this form
We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.

* Insurance coverage cannot be bound or altered by this submission.