Date Insurance Needed
*
Name of Business
*
Types of Entity
*
Location Address
*
City
*
State
*
Zip
*
Mailing address if different
Main Telephone
*
Main Mobile
*
Fax Number
Contact person
*
Contact Person Phone Number
*
Contact Person Email
*
Click One
Restaurant
Tavern/Bar
Nightclub
Website Address
Number of Owners
Years in Business
Years operating this business
Annual Gross Receipts
Annual Liquor Receipts
Liquor License Number
Number of Full Time Employees
Number of Part Time Employees
Annual Employee Payroll
Current Work Comp policy?
Yes
No
No elements found. Consider changing the search query.
List is empty.
Property Coverage
Year Built
Square Footage
Building Construction
Frame, Brick Veneer
Joisted Masonry or better
Non-Combustible
Metal
No elements found. Consider changing the search query.
List is empty.
Number of Stories
Theft Alarm
Yes
No
No elements found. Consider changing the search query.
List is empty.
Fire Sprinklers
Any losses in the last 3 years?
Yes
No
No elements found. Consider changing the search query.
List is empty.
If yes, please explain
Building (or Tenant Improvements) Coverage Amount
Business Personal Property Coverage Amount (contents)
Deductible:
Commercial Auto
Do you have a Commercial Auto Policy
Yes
No
No elements found. Consider changing the search query.
List is empty.
Is there any vehicles driven for business purposes?
Yes
No
No elements found. Consider changing the search query.
List is empty.
Do you deliver?
Yes
No
No elements found. Consider changing the search query.
List is empty.
Please include a copy of your existing declarations pages when returning this form. Policy numbers will be needed to order loss runs *
Questions or comments
I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (737) 777-6420 for assistance. You can reply STOP to unsubscribe at any time.
Privacy Policy