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?*

YesNo
Do you hold 100% ownership?

YesNo
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?*

Fine DiningCasual DiningTake-Out OnlyJuice/Coffee ShopOther
Describe Type of Restaurant:
Are you open year round or seasonally?*

Year RoundSeasonal
Are you open past 10pm?*

YesNo
Are you open past 2am?*

YesNo
Do you have multiple locations?*

YesNo
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?*

Workers CompensationGeneral LiabilityCommercial PropertyCommercial AutoEmployment Practices LiabilityCommercial UmbrellaCommercial Earthquake or FloodOther
Please confirm:

I am a tenantI own the building
Roof Age
Electrical Age
Plumbing Age
HVAC Age
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.

TrueFalse
Upload Driver List and Vehicle List:

Cancelof
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?*

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):

Cancelof
Reason for shopping insurance:*

Looking for price reliefLooking for a local agentLooking to switch agentsLooking for more optionsCurrent insurance is getting non-renewedNew VentureOther
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.*

Confirm
Should be Empty:

New Business Insurance Quote