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