Restaurant Business Owners Insurance Application
Requested effective Date
/
Month
/
Day
Year
Date
Business Name
Type of entity
Please Select
Sole Proprietorship
LLC
S-Corp
C-Corp
Partnership
Joint Venture
Non-profit
Contact name
First Name
Last Name
Contact email
example@example.com
Contact phone number
Tax ID#
required for workers comp insurance quotes
Type of Business
Mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Detailed Description of operations
Year this business started under the current ownership
Estimated annual gross sales
Years of total overall experience the owner has in this business type
Losses past 3 years
Yes
No
Upload your '3 year loss runs'
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Location address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Seating capacity
# of full-time employees
# of part-time employees
Estimated Total Annual Payroll
What are the total sales from food in a 12 month period of time?
If there are alcohol sales, what are the total sales from alcohol in a 12 month period of time?
Is there table service?
No
Yes
Are all hoods, ducts, grease filters, deep fryers and surface cooking equipment protected by a UL listed automatic fire extinguishing system serviced and inspected every 6 months?
yes
no
Are deep fat fryers used?
No
Yes
Are operations subcontracted or are subcontractors used for service, maintenance or repair work?
Yes
No
Enter total annual sales from banquet, and /or reception services, or 0 if none.
Enter total annual sales from catering, or 0 if none.
Are automatic high temperature shut offs on all deep fat fryers?
Yes
No
Are the subcontractors required to provide proof of insurance with General Liability limits that are at least equal to the applicant's?
Yes
No
Is emergency lighting installed and operational?
Yes
No
Are exits properly lit and equipped with panic hardware?
Yes
No
Does the applicant allow patrons to bring their own alcoholic beverages (BYOB)?
No
Yes
Is valet parking provided?
No
Yes
Does the applicant offer table side cooking?
No
Yes
Enter total annual sales from operation of mobile food units (e.g. food trucks, trailers or carts), or 0 if none.
Current insurance company
Current insurance company policy number
Current insurance company expiration date
-
Month
-
Day
Year
Date
Upload current workers compensation policy
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Would you like us to get you a quote on Worker's Compensation Insurance?
Yes
no
If you need business property coverage, please fill out this section
Year built
# of stories
Any residential units in the building?
No
Yes
If there are residential units in the building, how many?
Total square footage
Do you own the building?
No
Yes
Year roof was last updated/replaced
Year electrical was updated/replaced
Year plumbing was updated/replaced
Year water heater was updated/replaced
How much coverage do you need for business personal property
ex. furniture, equipment, inventory, etc.
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