Clone of Business Insurance - New Quote Intake Form

New Business Insurance Quote

Restaurant Intake Form
Business Name:
Contact Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
Are you the owner?
Do you hold 100% ownership?
List the Name, Title, and Ownership % of all officers (must equal 100%):
Business Type:
Description of Business:
(Include your web address if you have one)
What type of restaurant are you?
Describe Type of Restaurant:
Are you open year round or seasonally?
Are you open past 10pm?
Are you open past 2am?
Do you have multiple locations?
List all Locations:
Street Address, City, State, Zip
Physical Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Location same as Mailing Address?
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of years in business:
Number of years in the industry:
What type of coverage are you looking for?
Do you offer delivery service?
Is the building fully sprinklered?
Is there a central station burglar alarm in place?
Total area occupied by applicant:
Any live entertainment?
If yes, please explain.
Please confirm:
Roof Age
Electrical Age
Plumbing Age
HVAC Age
Upload Driver List and Vehicle List:

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FEIN:
Number of Full Time Employees:
Number of Part Time Employees:
Estimated Annual Payrolls - Restaurant:
Estimated Annual Payrolls - Clerical Only (if none, input $0):
Estimated Annual Sales - Food Only
Estimated Annual Sales - Delivery
Estimated Annual Sales
Estimated Annual Sales - Alcohol Only (if none, input $0)
Estimated Amount of Business Personal Property and Stock at your Location:
Estimated Limit for Tenant Improvement and Betterments to your Space (if applicable):
When does coverage need to take effect?

MonthDayYear
Do you currently have coverage in place?
Current Insurance Carrier:
Any losses in the last 5 years?
Explain any losses:
Upload 5 Years of Loss History (if available):

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Reason for shopping insurance:

Other
If you would like to exand on the above, or provide any additional notes to our agents, please provide detail below. (Optional)
Additional File Upload (Optional)

**Please upload anything that will help us quote your business. Examples include Declaration Pages, Photos, etc.
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I contest all the above information is true and accurate.
Should be Empty:

New Business Insurance Quote