New Business Insurance Quote
Restaurant Intake Form
Business Name:
*
Contact Name:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
Are you the owner?
*
Yes
No
Do you hold 100% ownership?
Yes
No
List the Name, Title, and Ownership % of all officers (must equal 100%):
Business Type:
*
Please Select
Corportation
LLC
Partnership
Individual
Trust
Other
Description of Business:
*
(Include your web address if you have one)
What type of restaurant are you?
*
Fine Dining
Casual Dining
Take-Out Only
Juice/Coffee Shop
Other
Describe Type of Restaurant:
Are you open year round or seasonally?
*
Year Round
Seasonal
Are you open past 10pm?
*
Yes
No
Are you open past 2am?
*
Yes
No
Do you have multiple locations?
*
Yes
No
List all Locations:
Street Address, City, State, Zip
Physical Location:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physical Location same as Mailing Address?
*
Please Select
Yes
No
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of years in business:
*
Number of years in the industry:
*
What type of coverage are you looking for?
*
Workers Compensation
General Liability
Commercial Property
Commercial Auto
Employment Practices Liability
Commercial Umbrella
Commercial Earthquake or Flood
Other
Please confirm:
I am a tenant
I own the building
Roof Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 years old
31+ years old
Unknown
Electrical Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 years old
31+ years old
Unknown
Plumbing Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 years old
31+ years old
Unknown
HVAC Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 years old
31+ years old
Unknown
I do not have any of the following at my location: Knob and Tube Wiring, Aluminum Wiring, Federal Pacific/Stab Lok Panels, Zinsco Panels, or Challenger Panels.
True
False
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
Estimated Annual Sales - Alcohol Only (if none, input $0)
*
When does coverage need to take effect?
*
-
Month
-
Day
Year
Do you currently have coverage in place?
*
Please Select
Yes
No
Current Insurance Carrier:
Any losses in the last 5 years?
*
Please Select
Yes
No
Explain any losses:
Upload 5 Years of Loss History (if available):
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Reason for shopping insurance:
*
Looking for price relief
Looking for a local agent
Looking to switch agents
Looking for more options
Current insurance is getting non-renewed
New Venture
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)
Browse Files
Drag and drop files here
Choose a file
**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.
*
Confirm
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