Restaurant & Nightclub Quote

General Information
Contact Name *
Email *

Business Name
Address
City
State
Zip
County
Business Phone
Fax
Current Insurance Company
(not agency)
Company Name
Policy Expiration Date
Annual Premium
Current Insurance Coverages
Current Coverages General Liability
Liquor Liability
Commercial Property
Commercial Umbrella
Workers' Compensation
Employers Practices Liability
Other
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Property/Premises Information
Address
Year Built
% Occupied
Sprinklers Yes  No
Construction Type
Stories
# Basements
Sq. Footage
Burglar Alarm Yes  No
Building Value
Contents
Other Property (specify)
Insurance Information
Annual Gross Sales: (before taxes)
Annual Alcohol Sales
Annualized Payroll
Limits Requested $300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you've had in the past 5 years
Additional Comments
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.