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Please fill out the form below:
Insured Name:
*
DBA:
Mailing Address:
Street Address
City
State / Province / Region
Postal / Zip Code
Website Address:
Contact Name:
First
Last
Phone:
Cell Phone:
Fax #:
Federal Employer ID:
State Employer ID:
Business Type
Partnership
Sole Proprietor
Corporation
LLC
Other
Number of Pizza Restaurants Owned:
Number of Employees:
Franchise?
Select value
YES
NO
Years in Business:
If under 3 Years, provide Owner's Prior Restaurant Experience:
Restaurant Locations
Address
City, State, Zip
County
Loc #1
Loc #2
Loc #3
Loc #4
List Addresses of any Separate or Additional Offices/Warehouses Where Coverage is Needed:
Desired Effective Date:
Current Coverage:
Carrier Name
Limits
Premium
Business Owners Policy/Package
Non-Owned Auto
Location Information:
Loc #1
Loc #2
Loc #3
Loc #4
Food & Beverage Sales (Not Including Delivery)
Alcohol Sales
Catering Sales
Delivery Sales
Total Annual Sales
If Own Building, What is Building Replacement Cost, including Attached Signs
Replacement Cost of Business Personal Property
Replacement Cost of Leasehold Improvements
Square Footage of Restaurant
Estimated Sq. Ft. of Other Tenants in Building
Estimated Total Sq. Ft. of Building
What % of Building is Vacant (if any)
Building Construction: (F = Frame, JM = Joisted Masonary, NC = Non Combustiblem NMC = Masonry Non Combustible, MFR = Modified Fire Resistive, or FR = Fire Resistive)
F
JM
NC
NMC
MFR
FR
Loc #1
Loc #2
Loc #3
Loc #4
Building Info
Loc #1
Loc #2
Loc #3
Loc #4
Number of Stories
Building Age (Year Built)
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