|
ABOUT THE OWNER / PRINCIPAL |
|
Company Name:
|
|
|
First Name:
|
|
|
Last Name: |
|
|
Address: |
|
|
City: |
|
|
State: |
|
|
Phone: |
|
| Zip Code: |
|
|
E-mail: |
|
|
Confirm E-mail: |
|
|
ABOUT THE BUSINESS |
| Name
of Business: |
|
| |
|
| Description of Restaurant
and what you serve: |
|
|
Year Started: |
|
|
|
Years experience in industry: |
|
|
| Tax ID # |
|
| |
|
| |
|
|
Commercial General
Liability / Business Owners Policy |
| |
|
|
General Liability Limits: |
$
|
| |
|
|
Space Occupied (sq feet): |
|
| |
|
| Gross Receipts: |
$ |
| |
|
|
Building Security System? |
|
| |
|
| Location: |
|
| |
|
|
Alcohol: |
|
| Alcohol Receipts: |
$
or write "none" |
|
PROPERTY INSURANCE
(added to the general liability quote) -
OPTIONAL |
| |
|
| Business personal property
and equipment? |
(office equipment, supplies, furniture) (we can quote
coverage for inventory and food spoilage based on your industry) |
| |
|
|
Year Building Built: |
(estimate is
acceptable) |
| |
|
|
Building Insurance? |
(optional and may include tenant improvement coverage, or for the building) |
| |
|
| *** |
Do you currently have insurance (if
yes, with what carrier?
|
| |
|
| |
Current Premium:
|
| |
|
| Prior Claims: |
|
| |
|
| |
Do you have any other information
about your business, or comments that you would like to
share? Please place special requests here, such as extra coverage
for special items. |
| |
|
| |
|
| |
|
|
|
|
|
| |
|
|
|
NO COVERAGE IS BOUND,
OFFERED, ISSUED THROUGH THIS ELECTRONIC COMMUNICATION, ALL POLICIES MUST BE
UNDERWRITTEN AND APPROVED BY THE CARRIER. DO NOT CANCEL YOUR CURRENT
INSURANCE. |
|
Copyright 2011 Stratum
Insurance Agency, LLC |
| |
|
|
|