Restaurant Liability Online Application

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information

First Name

Required

Last Name

Required

Describe type of establishment.

Required

Number of Owners

Optional

Business Type

Optional

Formal Name of Business

Required

DBA Name

Optional

Street

Required

City

Required

State

Required

ZIP / Postal Code

Required

Primary Phone Number

Required

How many locations?

Required

If you are a franchise, provide name of franchisor.

Required

Occupancy

Optional

Year Business Established

Required

How many years of experience do you have?

Required

Gross Annual Sales

Required

Number of Employees

Required

Amount Requested on Building Coverage

Optional

Amount Requested on Contents

Optional

Do you deliver?

Required

Do you have a liquor license?

Required

Is this a BYOB establishment?

Required

Square Footage

Required

Do you have a dance floor?

Required

Do you have entertainment? (DJ, band, singer, etc)

Required

Do you provide open broiling or solid fuel cooking?

Required

What are the hours of operation?

Required

Is this a fast food or limited cooking establishment?

Required

Does building have an automatic fire alarm with central station connectin and an automatic cooking exhaust and extinguishing system?

Required

If off-catering is provided, please estimate % of gross sales attributable to off-catering.

Required

Do you currently have insurance?

Required

Prior Insurance

Required

Current Premium

Required

Current Insurance Provider

Required

Effective Date

Required

Current Policy End Date

Required

Claims/Property Losses in Past 5 Years (Please Explain)

Required

E-Mail Address

Required

How did you hear about us?

Optional

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Insurance Websites Designed and Hosted by Insurance Website Builder

Quick Links

Applications Customer Service Payment Options Refer A Friend

About Us Our Carriers Blog Contact Us

Location

Mailing Address Only
P.O. Box 868
Oakhurst, NJ 07755