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

Business Type

Formal Name of Business(Required)

DBA Name

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

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

Amount Requested on Contents

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?

Restaurant Liability Online Application

Personal Information

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