1General Information

2Primary Contacts

3Business Information

4Property Information

5Fire & Cooking Systems

6General Operations

7Business Property

8Business Interruption

9Equipment Breakdown

10Workers Comp

11Commercial Auto

12Cyber Liability

13Crime Liability

14Electronic Data Processing

15Employment Practices Liability

16Additional Coverages

17Underwriting Information

18Upload Documents

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General Information

Legal Business Name(Required)

DBA (if applicable)

Business Entity Type(Required)

FEIN / Tax ID

Business Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing Address(Required)

Same as business address

Street Address Address Line 2 City State ZIP Code

Primary Contact and Owner(s)

Primary Contact Name(Required)

First Last

Company Title of Primary Contact

Phone Number(Required)

Email Address(Required)

Additional Owners

Click the (+) icon to add multiple additional owners.

Owner's Name (First & Last)

Pay/Salary ($)

Business Information

Website URL

Year Business Started(Required)

Example: 2005

Years of Operation(Required)

Years under current ownership(Required)

Description of Operations(Required)

Example: Full-service restaurant with bar and delivery service

Annual Gross Sales(Required)

Estimated Annual Payroll(Required)

Number of Full-Time Employees(Required)

Number of Part-Time Employees(Required)

Number of Temp/Seasonal Employees(Required)

Number of Leased Employees(Required)

Number of Independent Contractors(Required)

Business Hours

Do you operate from multiple locations?(Required)

Yes

If yes, list all addresses and describe operations at each.

Is the business a subsidiary or franchise of another organization?(Required)

Yes

Name of parent Organization(Required)

Property Information

Do you own or lease the building?(Required)

Own

Lease

If leased, provide landlord name and contact info.(Required)

Building construction type(Required)

Year built(Required)

Square footage(Required)

Number of stories(Required)

Any other tenants in the building?(Required)

Yes

If yes, describe type of business(es).

Year of Building Updates

If any of the following building areas have been updated, please enter the year completed here. Updated buildings get better insurance rates.

Roof (Important)

HVAC

Electrical

Plumbing

Area of surrounding premises(Required)

Downtown District

Industrial

Residential/Commercial

Resort

Rural

Seasonal

Shopping Center

Suburban Commercial

Waterfront

None

Does premises have a parking area?

Yes

Is premises located near a college or university?

Yes

Is smoking permitted on the premises?

Yes

Fire protection systems

Fully Sprinklered(Required)

Yes

Fire extinguishers(Required)

Yes

Ansul system over cooking surfaces(Required)

Yes

Cooking equipment details

Number of Cooking Facilities(Required)

Enter the number of each type of cooking facility. (Enter 0 if none)

Ranges

Ovens

Deep Fryers

Broilers

Grills

Other

Frequency of hood/duct cleaning(Required)

Are there deep fryers?(Required)

Yes

Are deep fryers located more than 16 inches from an open flame?(Required)

Yes

Do deep fryers have thermostats and high temperature limits(Required)

Yes

Is there an automatic fuel shut off?

Yes

Are there mats on the floors to prevent slip and fall injuries?

Yes

Does business serve any raw shellfish (including oysters)?

Yes

Does the business import any food products?

Yes

Are customers allowed to cook their own food?

Yes

Security systems (Alarm / Cameras / Monitoring)

Any history of property losses in the past 5 years?(Required)

Yes

List of Prior Losses

Click the (+) icon to add additional prior losses.

Briefly describe what happened

Date of loss

Amount of loss

General Operations

Seating capacity(Required)

Average daily patrons(Required)

Do you serve alcohol?(Required)

Yes

Annual alcohol sales (% of total sales)(Required)

Does the business currently have liquor liability insurance in force?(Required)

Yes

Is there a standalone bar?

Yes

Are bartenders trained in responsible service (e.g., TIPS/ServSafe)?

Yes

Any history of liquor liability claims?

Do you offer catering, delivery, or off-site services?(Required)

Yes

Type of service

Catering

Delivery

Off-site Services

Distance radius

Number of delivery drivers and ownership of vehicles

Do you have outdoor seating or patio service?

Yes

Are there any live entertainment or events (DJ, music, karaoke, dancing)?

Yes

Number of times per week live entertainment is performed

Please check any types of entertainment provided

Check all that apply

None

Live Music

Dance Floor

Happy Hour

Pool / Billiards

Karaoke

Arcade Games

Dart Boards

Other Amusement Devices

Dancers (including exotic)

Hookah or Hookah Bar

Oxygen Bar

Swimming Pool or Hot Tub

Alcohol without Liquid (AWOL)

Pyrotechnics

Firearms

Fighting Contests

Other

Describe Other type(s) of entertainment provided

Does business have or sponsor any "Teen" or "Under 21 nights" or permit patrons under the age of 21 in a bar area after 11pm?

Yes

Does business have any mechanical or amusement devices?

Yes

Are there any sports on the premises?

Yes

Is there any gambling?

Yes

Any special events (private parties, weddings, etc.)?

Any playground or recreational equipment on site?

Yes

Is there a valet parking service?

Yes

Are any bouncers/security personnel employed or contracted?

Yes

Business Property Coverage

Building value (if owned)

Contents value (furniture, kitchen equipment, inventory, etc.)(Required)

Does this location have any signage?(Required)

Yes

List of Signage

Click the (+) icon to add multiple types of signage.

Type of Sign

Cost to Replace

Any refrigeration or freezer units?(Required)

Yes

If yes, list approximate replacement value and number of units.

Are you interested in coverage for spoilage or power outage losses?

Yes

Business Interruption Coverage

Do you want coverage for lost income during a covered shutdown?(Required)

Yes

Average monthly gross income

Estimated time to rebuild after a major loss (months)

Are payroll and ongoing expenses to be included?

Include Payroll

Include Ongoing Expenses

Equipment Breakdown

Do you rely on specialized machinery (refrigeration, ovens, HVAC, point-of-sale systems)?(Required)

Yes

If yes: List critical equipment and estimated replacement cost.

Have you had any equipment failures or costly repairs in the past 5 years?

Workers’ Compensation

Job classifications (e.g., kitchen, waitstaff, management)(Required)

Are owners/officers to be included or excluded?(Required)

Included

Excluded

Any employees under 18?(Required)

Yes

Any history of workers’ comp claims in the last 5 years?(Required)

Yes

If yes, describe (dates, injuries, amounts).

Commercial Auto (if applicable)

Do you use vehicles for business purposes (delivery, catering, supply runs)?(Required)

Yes

Number of vehicles

List of Vehicles

Click the (+) icon to add multiple vehicles. If you have a schedule of vehicles you may skip entering vehicles here and upload your document before submitting this form.

VIN

Year

Make

Model

Ownership

Any vehicle modifications (refrigeration, branding)?

Radius of operation (miles)

Any driver training or MVR checks in place?

Yes

Any accidents in the past 5 years?

Cyber Liability

Do you accept credit/debit card payments?(Required)

Yes

Do you store customer data (names, emails, credit cards)?(Required)

Yes

Do you maintain employee personal information digitally?(Required)

Yes

Do you use a POS system connected to the internet?(Required)

Yes

Have you implemented data encryption or firewall protection?(Required)

Yes

Have you experienced a data breach or cyber incident in the past? If so, please describe

Crime Liability

Do you handle large amounts of cash daily?(Required)

Yes

Average cash on hand per day

Cash handling procedures (Deposits, dual control, cameras, safes)

Any prior incidents of employee theft or robbery?

Do you perform background checks on employees?

Yes

Is there a central safe or multiple registers?

Central Safe

Multiple Registers

EDP (Electronic Data Processing)

Do you rely on computers or POS systems for daily operations?(Required)

Yes

Value of hardware and software systems

Is data backed up daily?

Yes

Do you use cloud-based or local storage?

Cloud-based

Local Storage

Would you like coverage for hardware, software, and data restoration?

Yes

EPLI (Employment Practices Liability Insurance)

Total number of employees(Required)

Are references checked for all employees prior to hiring?(Required)

Yes

Do you have written employee handbooks or HR policies?(Required)

Yes

Do you have a written Sexual Harassment policy?(Required)

Yes

Do you conduct anti-discrimination or harassment training?(Required)

Yes

Any terminations, disputes, or lawsuits in the past 5 years?(Required)

Yes

If yes (terminations/disputes/lawsuits), describe details.

Any prior EEOC complaints? (Equal Employment Opportunity Commission)

Additional Coverages / Notes

Umbrella or Excess Liability desired?

Yes

Any owned real estate, subsidiaries, or affiliate businesses to include?

Special exposures (food trucks, franchise requirements, live music, valet, etc.)

Certificate Holders List

Click the (+) icon to add multiple certificate holders.

Certificate Holder Name

Relationship to Business

Additional Insured Required

Name of current insurance company

Current policy expiration date

MM slash DD slash YYYY

Underwriting Information

Has the business been cited for any health code violations?(Required)

Yes

Has business/location been cited for violations of beverage laws?(Required)

Yes

Are there procedures in place to handle unruly customers?(Required)

Yes

Has the business closed, sold, merged, or acquired any company in the past 12 months or anticipates doing so in the next 12 months?(Required)

Yes

Has the business insurance been cancelled or non-renewed in the last 3 years?(Required)

Yes

Have you ever filed for bankruptcy?(Required)

Yes

Has any entity proposed for insurance downsized, laid off or reduced staff in the past 12 months or anticipates doing so in the next 12 months?(Required)

Yes

Within the last 5 years, has any employment related, third party discrimination, or third party harassment inquiry, complaint, notice of hearing, claim or suit been made against any entity proposed for inurance or any person proposed for insurance in the capacityof either director, officer, member (if an LLC), or employee of any entity proposed for insurance?(Required)

Yes

Is any person proposed for this insurance aware of any fact, circumstance, or situation which may result in an employment related, third party discrimination, or third party harassment claim agains any entity proposed for insurance or any of its directors, officers, members (if an LLC) or employees?(Required)

Yes

Comments / Documents

Additional Comments

Upload Documents

Examples: Prior loss runs (5 years), Copy of lease, photos of premises, equipment list, payroll records, etc.

Drop files here or

Max. file size: 20 MB.

How were you referred to us?

Consent(Required)

Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

I Agree

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General Information

Primary Contact and Owner(s)

Business Information

Property Information

Fire protection systems

Cooking equipment details

General Operations

Business Property Coverage

Business Interruption Coverage

Equipment Breakdown

Workers’ Compensation

Commercial Auto (if applicable)

Cyber Liability

Crime Liability

EDP (Electronic Data Processing)

EPLI (Employment Practices Liability Insurance)

Additional Coverages / Notes

Underwriting Information

Comments / Documents

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