Company Name:

Street Address:

Town:

State:

ZIP:

Type of Eatery:

Bagel & Donut Shop Cofee Shop Deli Fast Food Ice Cream Parlor Pizzeria Family Style Restaurant Diner / Restaurant Fine Dining / White Linen Tavern or Bar Other

Do you currently have insurance?

Yes No

Years in Business:

Less Than One 1-3 Years 3-5 Years Over 5 Years

Property Coverage: (Complete if needed)

Fire Hydrants within 1000 Feet:

Yes No  

Fire Station within 5 Miles:

Yes No

Sprinklers:

Yes No  

Central Station Monitored Burglar Alarm:

Yes No  

Central Station Monitored Fire Alarm:

Yes No  

Cooking Devices:

Oven

Are all devices ansel protected?

Yes No

Year of Construction:

Building Construction Type:

Frame Masonary with Wood Roof Masonary with Steel Roof Fire Resistive  

Building Value (Enter $ Amount):

Contents Value (Enter $ Amount):

Deductible:

$250 $500 $1,000 $1,000+

Glass Coverage:

Yes No  

• Linear Feet (Enter #):

Sign Value (Enter $ Amount):

Liability Coverage:

Take-Out Only:

Yes No

Seating Capacity:

Waitress Service:

Minor Full None

Liquor Exposure:

BYOB None Service Bar Full Bar

Delivery Service:

Yes No

• If So, Describe:

Gross Annual Receipts (Enter $ Amount):

Gross Annual Payroll (Enter $ Amount):

Square Footage of Premises:

Additional Insured(s):

Yes No  

• Number Requested:

General Liability Limit:

$500,000 $1 Million  

Liquor Liability Limit (If Applicable):

$500,000 $1 Million  

Umbrella Liability (If Desired):

$1 Million $2 Million $2 Million+

Claims Information:

Any Property Claims within 3 Years:

Yes No  

• If So, Describe (Include Pay Out):

Any Liability Claims within 3 Years:

Yes No  

• If So, Describe (Include Pay Out):

Contact's Name:

Contact's Phone Number (Include Area Code):

Contact's Fax Number (Include Area Code):

Contact's E-Mail Address: