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General Information
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Full Name (First Middle Last)
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Mailing Address |
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Business Name
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City |
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Email Address
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State |
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Daytime Phone Number
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Zip Code |
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Fax Number
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Evening Phone Number
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How You Found Us
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If you found us by some other source not listed to the left, please specify below |
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Underwriting Information
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Form of Business
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Type of Restaurant |
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Years in Business at current Location
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Number of Staff |
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Full-Time Part-Time |
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Ansul System over all Cooking Surfaces
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Do you have a Deep Fat Fryer?
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Yes No
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Yes
No |
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Do you have any prior claims?
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Yes No
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Describe all claims made over the last 3 years
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Building & Contents
Information
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Full Physical Street Address of Building (if Different from Mailing Address)
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Is the Building Leased? |
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Yes No |
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City
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ZIP
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Replacement Cost of Building
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Replacement Cost of Contents (i.e., equipment, inventory, supplies etc.) |
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$
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Pershiable $ Non-Perishable $ |
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Value of Improvements/betterments (i.e, carpeting, walls, real property, etc.)
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Deductible: |
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$
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Type of Construction
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Year of Construction |
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Square Footage of Public Area
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Sprinkler System |
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Sq. Feet
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Yes
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Explain Other Occupancies in Same Building:
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Liability Insurance
Information:
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General Liability Limit
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Liquor Liability Limit |
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Annual Gross Sales
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Annual Gross Payroll |
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$
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$ |
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Percentage of Sales from Food
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Percentage of Sales from Liquor |
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%
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% |
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Current Insurance Coverage
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Current Insurer
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Renewal Date |
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(mm/dd/yy) |
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Premium
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$
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| Other Comments or Questions |
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