Name of Business:(Required) First and Last Name of Business Owner:(Required) First Last Phone Number:(Required)Email Address:(Required) Address of Business to be Insured:(Required) City:(Required) State:(Required)Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZip Code:(Required) Type of Restaurant:(Required)Select OneFast FoodBuffetCasual/Family DiningTake-out OnlyCafeteriaFine DiningCooking at your Table, such as BBQ or Hot PotBar/Tavern/NightclubConcessionaire/Food TruckCateringOpening Hours of Operation:(Required) Hours : Minutes AM PM AM/PM Closing Time of Operation:(Required) Hours : Minutes AM PM AM/PM Gross Sales:(Required)Food Sales:(Required)Liquor Sales (If none, Please put a Zero in this Field):(Required)Other Sales (If none, Please put a Zero in this Field):(Required)Does the Applicant have Liquor Liability in Force:(Required)Select OneYesNoTotal Seating Capacity:(Required)Is there any Table Service:(Required)Select OneYesNoDoes this Applicant rent out Spaces for Private Events, such as Weddings or Parties:(Required)Select OneYesNoWhat is the Square Footage of the Rental Space:(Required) Sales Generated from the Rental Space:(Required)Is there a Grease Chute for the Grill:(Required)Select OneYesNoHow often is the Grease Chute Cleaned:(Required)Select OneWeeklyMonthlyQuarterlySemi-AnnuallyAnnuallyAre deep fat Fryers Located more than 16" from an open Flame:(Required)Select OneYesNoDo the deep Fryers have Thermostats and high Temperature limits:(Required)Select OneYesNoIs all Cooking Equipment Located Beneath an Approved hood/duct System: :(Required)Select OneYesNoHow often are the hood and duct Cleaned:(Required)Select OneAnnuallySemi-AnnuallyQuarterlyAre the hood and duct Cleaned by a Commercial Firm:(Required)Select OneYesNoIs there an Automatic fuel shut off:(Required)Select OneYesNoAre there Portable Fire Extinguishers:(Required)Select OneYesNoWhat Number is Tagged on the Extinguisher:(Required) Date Extinguisher was Tagged:(Required) MM slash DD slash YYYY How Often are Refrigerator Compressors Inspected and Serviced:(Required)Select OneAnnuallySemi-annuallyQuarterlyDoes the Restaurant have 2 means of Egress:(Required)Select OneYesNoIs there a Fire Alarm:Select OneYesNoIf yes, is it:(Required)Select OneLocalCentralIs there a Burglar Alarm:(Required)Select OneYesNoIf yes, is it:(Required)Select OneLocalCentralIs there any Delivery Service:(Required)Select OneYesNoIf yes, by:(Required)Select OneBicycleCarOtherIf Other, Please Explain here:(Required) Delivery Service done by:(Required)Select OneEmployees of the InsuredOutside of Independent Firms (UberEats, Doordash):If you offer Catering service, is it:(Required)Select OneOn PremisesOff PremisesWhat Preparation and Sanitation Procedures are Followed to Prevent Foodborne Illness:(Required) Has the Applicant been Cited for any Health Code Violations:(Required)Select OneYesNoPlease Provide Citation or Violation Details(Required) What Controls are in place to avoid Over-Serving of Alcohol or Distribution to Minors:(Required) Do Bartenders have TIPS(Training for Intervention Procedures) Training:(Required)Select OneYesNoHas the Applicant been Cited for Violations of Beverage laws:(Required)Select OneYesNoPlease Provide Details of Citation or Violation:(Required) Please Indicate any Entertainment Provided:(Required) Select One Live Music Dance Floor Happy Hour Karaoke Hookah Arcade Games Amusement Devices Other If any Amusement Devices, Please Provide Details:(Required) If Other, Please Provide Details here:(Required) Is there a valet Parking Service:(Required)Select OneYesNoIf yes, is there a Separate Insurance for the Valet Parking Exposure:(Required)Select OneYesNoAre any Bouncers/Security Personnel Employed or Contracted:(Required)Select OneYesNoAre all Employee References Checked Prior to Hiring:(Required)Select OneYesNoOther Coverage Options:Would you like to add any Other Business Policy Coverages:(Required)Select OneYesNoWhat Other Coverage Options would you like (Select ALL that Apply):(Required) General Liability Business Property Insurance Commercial Auto Insurance Commercial Trucking Insurance Commercial Auto Quote:Do you have a Commercial Auto Policy now without a 30 day Lapse in Coverage:(Required)Select OneYesNoPrevious Insurance Company:(Required) Expiration Date:(Required) MM slash DD slash YYYY Insurance Policy Premium:(Required)Drivers:How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)Select One123456Driver 1:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Drivers License Number:(Required) Drivers License State:(Required)Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYAny Claims or Violations:(Required)Select OneYesNoValue of Violation:(Required)Date of Violation:(Required) MM slash DD slash YYYY Details of the Violation:(Required) Driver 2:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Drivers License Number:(Required) Drivers License State:(Required)Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYAny Claims or Violations:(Required)Select OneYesNoValue of Violation:(Required)Date of Violation:(Required) MM slash DD slash YYYY Details of the Violation:(Required) Driver 3:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Drivers License Number:(Required) Drivers License State:(Required)Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYAny Claims or Violations:(Required)Select OneYesNoValue of Violation:(Required)Date of Violation:(Required) MM slash DD slash YYYY Details of the Violation:(Required) Driver 4:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Drivers License Number:(Required) Drivers License State:(Required)Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYAny Claims or Violations:(Required)Select OneYesNoValue of Violation:(Required)Date of Violation:(Required) MM slash DD slash YYYY Details of the Violation:(Required) Driver 5:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Drivers License Number:(Required) Drivers License State:(Required)Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYAny Claims or Violations:(Required)Select OneYesNoValue of Violation:(Required)Date of Violation:(Required) MM slash DD slash YYYY Details of the Violation:(Required) Driver 6:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Drivers License Number:(Required) Drivers License State:(Required)Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYAny Claims or Violations:(Required)Select OneYesNoValue of Violation:(Required)Date of Violation:(Required) MM slash DD slash YYYY Details of the Violation:(Required) Vehicles:How many Vehicles Should be Added to your Auto Policy:(Required)Select One123456Vehicle 1:Year:(Required) Make:(Required) Model(Required) Vehicle Identification Number:(Required) Vehicle Usage:(Required)Select OnePersonalBusinessCommuteOtherVehicle 2:Year:(Required) Make:(Required) Model(Required) Vehicle Identification Number:(Required) Vehicle Usage:(Required)Select OnePersonalBusinessCommuteOtherVehicle 3:Year:(Required) Make:(Required) Model(Required) Vehicle Identification Number:(Required) Vehicle Usage:(Required)Select OnePersonalBusinessCommuteOtherVehicle 4:Year:(Required) Make:(Required) Model(Required) Vehicle Identification Number:(Required) Vehicle Usage:(Required)Select OnePersonalBusinessCommuteOtherVehicle 5:Year:(Required) Make:(Required) Model(Required) Vehicle Identification Number:(Required) Vehicle Usage:(Required)Select OnePersonalBusinessCommuteOtherVehicle 6:Year:(Required) Make:(Required) Model(Required) Vehicle Identification Number:(Required) Vehicle Usage:(Required)Select OnePersonalBusinessCommuteOtherBusiness Property:Business Services Provided:(Required) Value of Business Property:(Required)Desired Total Liability Amount:(Required)Expected Sales for the Year:(Required)Claims or Losses:Have you had any Claims or Losses at this or any Other Addresses in the Past 5 years:(Required)Select OneYesNoValue of Loss:(Required)Date of Loss:(Required) MM slash DD slash YYYY Details of Loss:(Required) General Liability:Desired Liability Amount:(Required)Expected Sales for the Year:(Required)Number of Years of Business Experience in Field:(Required)Number of Employees Total:(Required)Number of Full-Time Employees:(Required)Number of Part-Time Employees:(Required)Do you have all Required Licenses or Permits:(Required)Select OneYesNoIs all Work done in State:(Required)Select OneYesNoCommercial Trucking Quote:Business Structure:(Required)Select OneSole ProprietorshipPartnershipLimited Liability CompanyCorporationDo you haul goods for:(Required)Select OneOthersYourselfBothWhat do you haul:(Required) Are any Hazard Placards ever Required:(Required)Select OneYesNoWhat Products or Numbers:(Required) What is your Radius of Operations in Miles:(Required)Select One50100200300400500Over 500Is there any Permanently Attached Equipment or Hardware:(Required)Select OneYesNoTotal Approximate Value of Attached Equipment or Hardware:(Required)Do you have a USDOT # Assigned:(Required)Select OneYesNoUSDOT Number:(Required) Does the Operating Authority Require any of These Insurance Filings:(Required)Select OneFederal/FMCSA Filing (Ex: BMC 91X)State/Local Filing (Ex: Form E)Both Federal and State are NeededNo Filings are NeededDo any of your Vehicles Travel Across State Lines:(Required)Select OneYesNoStates Traveled to:(Required) Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Drivers:How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)Select One1234Driver 1:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Drivers License Number:(Required) Drivers License State:(Required)Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYAny Claims or Violations:(Required)Select OneYesNoDetails of the Violation:(Required) Date of Violation:(Required) MM slash DD slash YYYY Value of Violation:(Required)Driver 2:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Drivers License State:(Required)Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYDrivers License Number:(Required) Any Claims or Violations:(Required)Select OneYesNoValue of Violation:(Required)Date of Violation:(Required) MM slash DD slash YYYY Details of the Violation:(Required) Driver 3:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Drivers License State:(Required)Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYDrivers License Number:(Required) Any Claims or Violations:(Required)Select OneYesNoValue of Violation:(Required)Date of Violation:(Required) MM slash DD slash YYYY Details of the Violation:(Required) Driver 4:Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Drivers License State:(Required)Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYDrivers License Number:(Required) Any Claims or Violations:(Required)Select OneYesNoValue of Violation:(Required)Date of Violation:(Required) MM slash DD slash YYYY Details of the Violation:(Required) Cargo and Trailer Coverage:Do you want Cargo Coverage:(Required)Select OneYesNoWhat Limit:(Required)What Deductible:(Required)Select One500100025005000Would you like Trailer Interchange Coverage (If you would like Trailer Coverage, Please add it as a Vehicle Below):Select OneYesNoWhat Deductible for Comp/Collision:(Required)Select One500100025005000Vehicles:How many Vehicles/Trailers Should be Added to your Commercial Trucking Policy:Select One1234Vehicle 1:Year:(Required) Make:(Required) Model(Required) Vehicle Identification Number:(Required) Vehicle Usage:(Required)Select OnePersonalBusinessCommuteTrailerOtherVehicle 2:Year:(Required) Make:(Required) Model(Required) Vehicle Identification Number:(Required) Vehicle Usage:(Required)Select OnePersonalBusinessCommuteTrailerOtherVehicle 3:Year:(Required) Make:(Required) Model(Required) Vehicle Identification Number:(Required) Vehicle Usage:(Required)Select OnePersonalBusinessCommuteTrailerOtherVehicle 4:Year:(Required) Make:(Required) Model(Required) Vehicle Identification Number:(Required) Vehicle Usage:(Required)Select OnePersonalBusinessCommuteTrailerOtherPlease Upload your Current Policy, any Inspections, or Wind Mitigation Reports you have:FileMax. file size: 98 MB.Anti-Spam Check:CAPTCHA
