Complete the following information if you would like to obtain a 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 * Last Name * First Name Business Name Street Address City State Zip Code Phone Number Alternate Telephone Fax Number * Email Address Property Information Property Street Address City State Zip Code Total square footage of the building your business is in Total square footage of your business only Total square footage of the customer area only How many stories is it? If it's two stories, what is the ground floor square footage? What is the construction type? -Select- Brick Stone Frame Masonry Superior Log Cabin Frame-Stucco Masonry Veneer What type of roof covering? Was the roof updated? Yes No If yes, what year? What is the distance to fire protection? -Select- 1000 ft or less to hydrant and 5 mi or less to fire station Over 1000 ft to hydrant and 5 MI or less to fire station Over 5 and up to 10 MI to fire station Over 10 MI to fire station Is the business in a brush area? Yes No Do you have a storage area more than 1500 Sq. Ft.? Yes No Are there smoke detectors at this location? Yes No Are there fire extinguishers? Yes No Does the building have interior automatic fire sprinklers? Yes No Is there a fire alarm? Yes No Is there a theft alarm? Yes No Are there deadbolts on all doors? Yes No Are there circuit breakers? Yes No Is the electrical updated? Yes No Is the heating / air conditioning thermostatically controlled? Yes No Is the heating/ air conditioning central? Yes No Has the plumbing been updated? Yes No If yes, what year? Is the parking lot under your protection? Yes No Underwriting Information What is the nature of your business? Number of owners Number of Employees Payroll of Owners Payroll of Employees Total annual gross receipts Total annual hard liquor receipts Total annual beer and wine receipts Total annual food gross receipts Business License Number License Type Years of experience Years operated under current name Is this business open 24 hours a day? Yes No Is there filling of propane tanks? Yes No Please describe the nature of your business and ANY unusual exposures: Entertainment Information Is there entertainment? Yes No If yes, please describe Is there 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? Yes No If yes, please describe Are there any pool tables? Yes No If yes, how many and are they coin operated? Are there any 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? Yes No If yes, describe events. Are there any audience participation events? Yes No If yes, describe events. Do you sponsor any sporting events? Yes No If yes, describe events. Do you have any other type of entertainment? Yes No If yes, describe events. Cooking Information Describe the cooking devices at your business. Is there tableside cooking? Yes No Is there an automatic suppression system? Yes No If yes, do they protect all hoods, ducts and griddles? Yes No Is there any deep frying? Yes No If yes, is there a high limit shutoff? Yes No Do you have an outside cleaning service for the hoods and duct system? Yes No How often are hood and duct cleaned? Is there any manufacturing, mixing, re-labeling or repackaging of products? Yes No Is there any delivery service? Yes No Is there any catering service? Yes No Miscellaneous and Claims Information Were there any losses or claims in the last 5 years? Yes No If yes, what is the date, amount paid and description of each loss or claim? Current Insurance Company How much are you paying now? What is the renewal date? Has insurance ever been cancelled? Yes No If yes, describe. Have you ever had regulatory violations or citations? Yes No If yes, describe. Are employees trained on how to handle minors or intoxicated customers? Yes No If yes, describe. Coverage Information What building coverage is requested? What other structures is requested? What business contents is requested? What is the loss of use coverage requested? What is the liability limit requested? -Select- 100,000 300,000 500,000 1,000,000 What policy deductible is requested? -Select- 100 250 500 750 1000 2500 5000 Questions or Comments Best Time To Contact You Please let us know the best time to call and discuss your quote. Morning Afternoon Evening Anytime Or Specify Other: Before submitting, type in required validation security code: d1que4