Fire & Liability

Please answer completely so we can quote accurately:

# of years in business at above location: Annual Food Sales: Annual Alcohol Sales: Type of Food Served Is there entertainment? Yes No Age of building where your establishment is located? Service Contract for hood Cleaning? Yes No Monthly Quarterly Semi-Annual None Central Station Alarm System: Yes No None Burglary Only Fire Only Burglary & Fire Is Building fully Sprinklered? Yes No Business Liability Protection Limit: $1,000,000 $2,000,000 $3,000,000 $5,000,000

Building Protection Coverage Limit: N/A Contents Protection Coverage Limit: Tenant Improvements Coverage Limit: Do you currently have insurance? Yes No Name of Insurance Company (not agent): Present Premium: Current Policy Expiration Date (mm/dd/yy): Have there been any losses or claims in the past 5 years? Yes No Any bankruptcies, tax or credit liens against the applicant in the past five years? Yes No

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"Real" Work Comp or Comp "Alternative"

Please quote: "Real" Work Comp Comp "Alternative" Both Please answer completely so we can quote accurately:

Are You Currently Insured? Yes No Will Owners be Covered? Yes No Current Workers Comp Carrier: Number of Owners: 1st Classification (Description of Work): Clerical/Office Employee-8810 Executives Doing Admin-8809 Restaurant, All Other-9079 Delivery-8742 Other-Please Describe # of Full-Time Employees: # of Part-Time Employees: Gross Annual Payroll 2nd Classification (Description of Work): Clerical/Office Employee-8810 Executives Doing Admin-8809 Restaurant, All Other-9079 Delivery-8742 Other-Please Describe # of Full-Time Employees: # of Part-Time Employees: Gross Annual Payroll

3rd Classification (Description of Work): Clerical/Office Employee-8810 Executives Doing Admin-8809 Restaurant, All Other-9079 Delivery-8742 Other-Please Describe # of Full-Time Employees: # of Part-Time Employees: Gross Annual Payroll Any Workers Paid on 1099 Rather Than W-2 Basis? Choose One Yes No List Your Experience Modification (if known): My Policy Renews: Month Choose One January February March April May June July August September October November December Year Choose One 2008 2009 2010 2011 2012 2013 2014

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