EmailMe Form - Bar/Restaurant/Tavern Quote Form

Named Insured *

Doing Business As *

Location Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Web Address

Business Email *

Phone Number *

### - ### - ####

Mailing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Current Carrier *

Effective/Renewal Date *

MM / DD / YYYY

Current/Target Premium *

Has Current policy been canceled or non-renewed? *

If yes, describe

Owners Name (Principal) *

Social Security Number *

Date of Birth *

MM / DD / YYYY

Home Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone *

### - ### - ####

Business Phone

### - ### - ####

Applicant is a *

If Other, Describe

Applicant is located in *

Number of years at this location? *

Number of years in the Restaurant/Tavern Business? *

If less than 3 years, list previous experience

Federal EIN Number? *

Liquor License Number? *

Legal Building Occupancy? *

Is this a Franchise? *

Is this a Chain? *

Is the Applicant open now? *

If no, please explain

Open Time *

HH : MM AM/PM

Close Time *

HH : MM AM/PM

Number of Days per week? *

What is the distance to the nearest body of water and what is the type of body of water? *

Is the Owner or Corporation now or ever involved in any of the following?

Bankruptcies? *

Foreclosures? *

Tax Liens? *

Business Failures? *

Any Litigations? *

If yes to any, please explain

PHYSICAL PLANT SECTION

Are any bouncers, door persons, crowd control, or security used? *

If yes, please describe

Are any non-employee security services hired or contracted? *

If yes, please describe type and purpose

In the last 12 months, have any emergency services been called? *

i.e. Police, Fire, or Ambulance

If yes, explain why and what happened

NON-OWNED AUTOMOBILE SECTION (HIRED AUTO NOT AVAILABLE)

Is non-owned automobile coverage requested? *

Number of employees?

Does applicant have a business auto policy?

Is there any delivery use?

Give the business purposes the non-owned auto coverage will be utilized for?

PRIOR CLAIMS SECTION

Over the past 5 years, have you had any property, general liability, or liquor liability claims? *

If yes, please describle the loss and the amount paid by the insurer

ADDITIONAL INSURED SECTION

Are there any additional insureds or Loss Payees needed added to the policy? *

If yes, please give name, address, phone number and type of Additional Interest

If there are additional owners or share holders in the company, please list below

Name - % owned of business - Date of birth - Social Security Number

Are there any additional Comments or Notes you'd like to share?

Referring Agent