Restaurant & Liquor Liability Insurance

Restaurant, Caterers & Taverns

Full Name(Required)

First Last

Legal Name of Business (DBA)(Required)

Business Type(Required)

Years in business under this name?(Required)

Primary Phone Number

Email(Required)

Physical Location of Restaurant(Required)

Street Address City State / Province / Region ZIP / Postal Code

Years at the Current Location(Required)

Is the Restaurant locatedf in a Shopping Center or Stand Alone Building?(Required)

What type of insurance do you want us to quote

Describe Restaurant or Your Service(Required)

Cooking Style, Select which applies

Wood Burning BBQ Pit

Table Top Cooking

Open FLame Cooking

Kitchen Cooking at Restaurant

Mobile Cooking

Is there a Cooking Ventilation System?(Required)

Is there an In-Force Cleaning Contract?(Required)

Total Building Square Footage (estimated)(Required)

Your Occupied Square Footage(Required)

Maximum Seating Capacity?(Required)

How Many Owners/Officers?(Required)

Annual Employee Payroll (Excluding Owners or Officers)(Required)

Number of Employees(Required)

Annual Gross Sales (Incluidng any Alcohol Sales)(Required)

Do you sell alcoholic beverages?(Required)

If YES to Alcohol Sales, What % of Gross Sales for Alcohol? If Not Write NA(Required)

Valet Parking, Provided?(Required)

Is there any Type of Enterainment at the Restaurant(Required)

Any Claims past 36 months from today?(Required)

If Claims, please describe including the Year(Required)

Current Restaurant Liability Carrier(Required)

Current Work Comp Insurance Carrier(Required)

Is there anything you would like to tell us about your Quote Request?

Please Let us know - How did you hear about us?(Required)

SIGNATURE REQUIRED

I have provided all of the above information for insurance purposes and I state all information is true to the best of my knowledge. I also understand that I am to discuss with the agent at D. Ward Insurance my desired limits and coverage.

By typing my name warrants my signature.(Required)

First Last

ADDITIONAL INFORMATION NEEDED

After you have sumitted your quote request, we will start working on your quote and we will help assist with obtaining your claim history. The insurance carriers require us to show prior proof of coverage along with claim history. Thank you for your time and we will be in touch with you today unless this is after hours or on the weekend.

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Restaurant & Liquor Liability Insurance

Restaurant, Caterers & Taverns

SIGNATURE REQUIRED

ADDITIONAL INFORMATION NEEDED

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