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Complete the following information if you would like to obtain a Restaurant Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
What is your business name?
Business Name
What is your address?
What is your telephone number?
What is your fax number?
What is your email address?
Property Information
What is the Property Address?
Property Street
Property City
Property State
Property Zip
What is the total square footage of the building your business is in?
Total Square Footage of Business Building
What is the total square footage of your business only?
Total Square Footage of Business Only
What is the square footage of the customer area only?
Square Footage of Customer Area
How many stories is it?
If it's two stories, what is the ground floor square footage?
Ground Floor Square Footage
What is the construction type?
Construction Type
What type roof covering?
Was the roof updated?
Roof Updated
Yes No
If yes, what year?
Year Roof Updated
What is the distance of fire protection?

Is the business in a brush area?
Yes No
Do you have a storage area more than 1500 Sq. Ft.?
Storage Area
Yes No
Are there smoke detectors at this location?
Smoke Detectors
Yes No
Are there smoke alarms at this location?
Smoke Alarms
Yes No
Are there fire extinguishers?
Fire Extinguishers
Yes No
Does the building have interior automatic fire sprinklers?
Automatic Fire Sprinklers
Yes No
Is there a fire alarm?
Fire Alarm
Yes No
Is there a theft alarm?
Theft Alarm
Yes No
Are there deadbolts on all doors?
Yes No
Are there circuit breakers?
Circuit Breakers
Yes No
Is the electrical updated?
Electrical Update
Is the heating/ air conditioning thermostatically controlled?
Thermostatically Controlled
Yes No
Is the heating/ air conditioning central?
Yes No
Has the plumbing been updated?
Plumbing Updated
Yes No
If yes, what year was the plumbing updated?
Year Plumbing Update
Is the parking lot under your protection?
Parking Protection
Yes No
Underwriting Information
What is the nature of your business?
Nature of Business
How many owners?
Number of Owners
How many employees?
Number of Employees
What is the payroll amount of the owners?
Payroll of Owners
What is the payroll amount of the employees?
Payroll of Employees
What is the total annual gross?
Total Annual Gross Receipts
What are the total annual hard liquor receipts?
Hard Liquor Receipts
What are the total annual beer and wine receipts?
Beer and Wine Receipts
What are the total annual food gross receipts?
Food Receipts
What is the business license number?
Business License Number
What is the license type?
License Type
Years of experience in this business?
Years of Experience
How many years have you operated this business?
Years Operated Under Current Name
Is this business open 24 hours a day?
Open 24 Hours
Yes No
Is there filling of propane tanks?
Propane Tank Filling
Yes No
Please describe the nature of your business and ANY unusual exposures.
Unusual Exposures
Entertainment Information
Is there entertainment?
Yes No
If yes, please describe.
Is there live music?
Live Music
Yes No
If yes, what size is the dance floor and how many nights per week is there dancing?
Are there any coin operated amusement devices?
Coin Operated Amusement Devices
Yes No
If yes, please describe
Are there any pool tables?
Pool Tables
Yes No
If yes, how many and are they coin operated?
Are there any bouncers, doormen, ID checkers, armed or security guards?
Bouncers, Doormen, ID Checkers, Armed or Security Guards
Yes No
If yes, how many of each? (list their job duties and employer)
Are there any contests or exhibition?
Contests or Exhibitions?
Yes No
If yes, describe events.
Are there any audience participation events?
Audience Participation Events
Yes No
If yes, describe events.
Do you sponsor any sporting events?
Sponsor Sporting Events
Yes No
If yes, describe events.
Do you have any other type of entertainment?
Any Other Type of Entertainment
Yes No
If yes, describe events.
Cooking Information
Describe the cooking devices at your business.
Is there tableside cooking?
Tableside Cooking
Yes No
Is there an automatic suppression system?
Automatic Suppression System
Yes No
If yes, do they protect all hoods, ducts and griddles?
Protect Hoods, Ducts and Griddles
Yes No
Is there any deep frying?
Deep Frying
Yes No
If yes, is there a high limit shutoff?
High Limit Shutoff
Yes No
Do you have an outside cleaning service for the hoods and duct system?
Outside Cleaning Service
Yes No
How often are hood and duct cleaned?
How Often Cleaned
Is there any manufacturing, mixing, re-labeling or repackaging of products?
Yes No
Is there any delivery service?
Delivery Service
Yes No
Is there any catering service?
Catering Service
Yes No
Claims and Miscellaneous Information
Where there any losses or claims in the last 5 years?
Losses - Claims
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
What is the current insurance company?
How much are you paying now?
Amount Current Coverage
What is the renewal date?
Renewal Date
Has insurance ever been cancelled?
Insurance Cancelled
Yes No
If yes, describe.
Have you ever had regulatory violations or citations?
Regulatory Violations or Citations
Yes No
If yes, describe.
Are employees trained on how to handle minors or intoxicated customers?
Employees Trained
Yes No
If yes, describe.
Coverage Information
What building coverage is requested?
Building Coverage
What other structures is requested?
Other Structures Coverage:
What business contents is requested?
Business Contents Coverage:
What is the loss of use coverage requested?
Loss of Use Coverage:
What is the liability limits requested?
Liability Limits Requested:
What policy deductible is requested?
Policy Deductible:
Are there any questions, comments or additional coverage required?
Questions, Comments or Additional Coverage
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Or specify other:

Phone 334-687-0358 or 888-882-2181
Fax 334-687-2365
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