# of years in business under current ownership

Annual Food Sales:

Annual Alcohol Sales:

Type of Food Served

Is there entertainment?
Yes No

Age of building where your establishment is located?

Service Contract for hood Cleaning?
Yes No  
Select One Monthly Quarterly Semi-annual

Central Station Alarm System:
Yes No
Select One None Burglary only Fire only Burglary & Fire

Is Building fully Sprinklered?
Yes No

Business Liability Protection Limit:
Select One $1,000,000 $2,000,000 $3,000,000 $5,000,000

Building Protection Coverage Limit:
 
N/A

Contents Protection Coverage Limit:

Tenant Improvements Coverage Limit:

Do you currently have insurance?
Yes No

Name of Insurance Company, not agent

Present Premium:

Current Policy Expiration date
mm/dd/yy

Have there been any losses or claims in the past 5 years  Y-N
Yes No

Any bankruptcies, tax or credit liens against the applicant in the past five years?
Yes No

How Did You Find Us?

Select Letter or Postcard Referred by a Friend By a Restaurateur AOL Search Overture. Search Google.com Search Yahoo Search Alta Vista Search Excite Search Lycos Search Infoseek / GO Search Galaxy Search Dog Pile Search Other

Minimum: $100,000 of Employee Payroll

Type of Restaurant

Select Bakeries - Family Style Bakeries - Fast Food Barbecue Places - Fam Style Barbecue Places - Fast Food Cafeteria Style/Buffet Chicken - Fast Food Cafes Coffee Shops Concession Stands/Snack Bar Delicatessens - Family Style Delicatessens - Fast Food Diners Donut Shops Drive-Ins/Service in Car Full Menu - Family Style Hamburger/Malt Shops-Fam Hamburger/Malt Shops-Fst Fd Hot Dog Stands Ice Cream/Yogurt Stores Mexican Style - Family Style Mexican Style - Fast Food Oriental - Family Style Oriental - Fast Food Pancake/Waffle House Pizza Parlors - Family Style Pizza Parlors-W/Full Cook Pizza Parlors-W/Oven Only Roast Beef - Fast Food Seafood Rest. - Family Style Seafood Rest. - Fast Food Steak House Take Out Only Other ( Restaurants N.O.C.)

Are You Currently Insured?

Select Yes No

Will Owners be Covered?

Select Yes No

Type of Business

Select Corporation Individual Parntership LLC Other

Current Workers Comp Carrier:

Number of Owners

List Your Experience Modification (If Known)

My Policy Renews:

Month

Year

Please Provide a Description of Your Operations. The more you tell us the more accurate the quote.