Applicant
Location(s)
Additional Parties
Business Details
Restaurant/Bar Info
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Applicant
*
Contact Person
*
Email
*
Phone
*
Fax
Mailing Address
Street
*
City
*
State
*
Zip
*
Do you have one or more physical locations?
*
Select an option
Yes
No
Additional Insured(s)
Add Additional Insured
Limit Required
*
Select an option
$500,000
$1,000,000
$2,000,000
$5,000,000
Complete Details of Operation
*
Business Information
Form of Business
*
Select an option
Individual
Partnership
Corporation
S Corp
LLC
Other
Years in Business
*
Experience in Business (if different from above
*
Any Claims or Losses in Past 5 Years
*
Select an option
No
Yes
If yes, please explain those claims or losses
Annual Sales
*
$
Payroll
$
Square Footage
*
Is the operation a Restaurant or Bar?
*
Select an option
Yes
No