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 Restaurant | Garage | Business Owners Program | Workers Comp
 
No coverage is bound until you are contacted by one of our representatives.
Business Insurance Quote
 

No coverage is bound until you are contacted by one of our representatives.
Name:
Business Name:
Street Address:
Street Address:
City, State, Zip:
Phone Numbers: Home: Work: Cell:
E-mail Address:
Business Activites
1. Type of Organization:
2. How Many Owners, Partners, or Officers?
3. How Many Employees - excluding owners,
partners, or officers?
4. Date Business Started?
5. Last Year's Payroll:
6. This Year's Projected Payroll:
7. Last Year's Gross Sales:
8. This Year's Projected Sales:
9. Describe Your Normal Business Activities:
10. Have you had liability losses or claims in
the past 3 years?
If yes, please give description, date, and amount paid for each:
Property  Information
a. Year Building Was Built:
b. Type of Building Construction:
c. Number of Stories
d. Other Occupancies:
e. Total Square Feet:
f. Square Feet You Occupy:
If The Building Is Over 25 Years, Please Answer the Following:
f. Year Electricity was Updated:
g. Is it on Circuit Breakers:
h. Year Plumbing was Updated:
i. Copper or Galvanized Plumbing: If Other:
Protective Devices:
22. Do you have a security system?
If yes, please describe what type:
Burgler Alarm:
Type of Alarm:
Alarm Company:
Sprinkler System In Building:
Smoke Detectors:
23. Have you had any property losses in the
past 3 years?
If Yes, Please Describe:
Prior Coverage
1. Previous Carrier:
2. Policy Number:
3. Prior Premium $:
4. Policy Renewal Date:
5. Continuous Coverage
in Force Since:
Desired Coverage
Liability Coverage Limit:
Property Coverage Limit: Deductible:
Buildings Coverage Limit: Deductible:
Contents Coverage Limit:   Deductible:
Signs Coverage Limit: Deductible:
Other If Other: Coverage Limit:
Other If Other: Coverage Limit:
Other If Other: Coverage Limit:
Additional  Insured
Name:
Address:
Phone #: Phone: Fax:
Account/Loan #:
Lienholder/Mortgage Info
Name:
Address:
Phone #:
Fax #:
Loan #:
Legal Description:
Building Owned or
Leased:
Comments:

 

    

 
Restaurant Quote Request
Number of years in business under current ownership?
At this location?
Has the owner ever been involved in a bankruptcy or business failure? Yes     No
If needed, will financial statements be provided prior to banding? Yes     No
What are the gross sales for the past 3 years?
Year: Food: $ Liquor: $
Year: Food: $ Liquor: $
Year: Food: $ Liquor: $
What are the hours of operation?
Is the business seasonal? Yes     No
Months of operation: to
Is there a bar or lounge? Yes     No
If Yes, Describe:
Is there a happy hour? Yes     No
If liquor is served, describe the training protocol for liquor servers:
Is there live entertainment? Yes     No
If yes, describe (type, nights per week, hours, etc.)
Is there a dance floor(s)? Yes     No
If yes, what is the size?
Are there any operations away from the premises, such as catering? Yes     No
If yes, explain:
Any tableside cooking or food preparation? Yes     No
Was the building originally built as a restaurant? Yes     No
If no, has wiring, etc., been updated from restaurant occupancy? Yes     No
If yes, when?
Which floor is the restaurant located on?
Maximum Seating Capacity of Restaurant:    Of Lounge:
Number of exits:
Are all exits free of obstruction, lighted and marked with exit signs? Yes     No
Is there emergency lighting? Yes     No
Has insured ever been cited by Board of Health? Yes     No
If yes, explain:
Housekeeping: Excellent    Good    Fair    Poor
Valet Parking: Yes     No
Is there a coat check room? Yes     No
Are all areas over ranges, grills, fryers, and all other cooking surfaces, hoods, and ducts protected by a ULB00-compliant automatic fire extinguishing system? Yes     No
Is there a maintenance agreement to regularly inspect and service the system? Yes     No
Times per year
Are the employees trained in the use of an automatic extinguishing system and portable fire extinguishers? Yes     No
Is there a maintenance agreement with an outside firm to clean the hood and duct system? Yes     No
Times per year
If no, explain:
How often are the grease filters cleaned by the employees?
   

    

 
Business Owners Program
Location for this quote (Address, City, State, Zip):
Please answer these questions based on your primary location and building. If you have additional locations or buildings, please submit another copy of this section and answer the questions for your other property. Home based businesses should complete the following questions based on the business portion of the home.
What is the desired Property Deductible? $500  $1,000  $5,000  $10,000
Is the business within 5 miles of a fire station? Yes     No
What is the 100% replacement value of the business personal property (including business contents, fine arts, value of all computer hardware and software and laptops)?
What is the construction of the building where the business is located? Frame (wood)  Joisted Masonry (brick)
Non-combustible (steel)  Fire resistive
Masonry non-combustible (tilt-up concrete)
If the construction of the building is not known, please provide details on the materials used for the roof, floors, and walls.
What is the square footage of the space occupied by the business?
Is the business the sole occupant of a free standing building? Yes     No
Does the building have an automatic sprinkler system covering 100% of the premises? Yes     No
Does the business have a central station burglar alarm? Yes     No
Is there any use of grills or deep fat frying in your business operations or in any other businesses in your building? (i.e. restaurant in the same building) Yes     No
Please indicate whether the following optional coverages are desired:
a) Earthquake Coverage (not available in all areas): Yes     No
b) Sprinkler Leakage - Earthquake: Yes     No
c) Flood Coverage (not available in all areas): Yes     No
d) Computer Mechanical Failure and Computer Virus Coverage ($100,000 limit): Yes     No
e) Systems Breakdown Coverage? (i.e. boilers, pressure vessels, AC units, etc.) Yes     No
f) Mine Subsidence Coverage (KY, IL, IN, WV only): Yes     No
g) Business Income from Dependant Properties ($10,000 limit): Yes     No
h) Personal Property Off Premises and Property in Transit Limited International Extension Endorsement: Yes     No
i) Business Income Sub-limit: Yes     No
If Yes, choose limit option desired: $100,000  $200,000  $300,000
$400,000  $500,000
j) Business Income Waiting Period Deductible (24 hours): Yes     No
k) Business Income Off Premises Power Failure ($10,000 limit): Yes     No
Please indicate whether any of the following exclusions are desired:
a) Business Income Exclusion: Yes     No
b) Theft Exclusion: Yes     No
c) Windstorm and Hail Exclusion: Yes     No
d) Stock Exclusion: Yes     No
What is the total maximum daily value of money and securities (i.e. checks) on the premises?
The policy includes limits of $10,000 inside the business and $2000 while being delivered to the bank. If higher limits are desired, choose one of the following options: (Please note that in order to receive higher limits use of a safe on premises is required) $20,000/$4,000     $30,000/$6,000

$40,000/$8,000     $50,000/$10,000
If loss of refrigeration coverage is desired, please provide the total value of property subject to refrigeration:
Many property coverage forms provide for coverage similar to the limits below. If you require higher limits than listed, please list below.

Separate Limits for Each Coverage (unless you choose a blanket limit):
Fire Dept. Service Charge/Fire Extinguisher Recharge: $2,500
Forgery and Alteration: $2,500
Glass: $2,500
Customers' Goods on Premises: $10,000
Personal Property Off Premises: $5,000
Valuable Papers / Records on Premises: $10,000
Employees Dishonesty - ERISA: $2,500
Money Orders and Counterfeit Currency: $2,500
Increased Construction Cost (after a loss): $5,000
Signs: $2,500
Backup of Sewer/Drains: $2,500
Property In Transit: $5,000
Accounts Receivable at the Premises: $10,000
Indicate coverage area where you will require limits higher than shown above:
Complete the following questions only if interested in purchasing insurance for the building. Home based businesses do not need to complete these questions.
What is the 100% replacement value of the building?
Are you interested in having a blanket limit for both building and business personal property? Yes     No
What is the square footage of the entire building?
How many stories in the building?
What is the original year the building was built?
If the building(s) is over 30 years old, indicate the year each of the following was updated:
Electrical: Roofing: Plumbing: Heating:
       

    

 
Garage Owners Quote Request
Years in Business:
Years Sales/Repair Experience:
Business Entity:
Individual          Partnership          Corporation
Describe your Operations:
Locations where you conduct Garage Operations:
Location 1:
Location 2:
Underwriting Information List of Drivers (Owners, Employees, Family)
Name:
Drivers License #:
State of License:
Date of Birth:
Furnished Auto: Yes     No
Past 3 Years Number of:  
Accidents:           Citations:
Job Description and/or Relation:
Name:
Drivers License #:
State of License:
Date of Birth:
Furnished Auto: Yes     No
Past 3 Years Number of:  
Accidents:           Citations:
Job Description and/or Relation:
Name:
Drivers License #:
State of License:
Date of Birth:
Furnished Auto: Yes     No
Past 3 Years Number of:  
Accidents:           Citations:
Job Description and/or Relation:
Name:
Drivers License #:
State of License:
Date of Birth:
Furnished Auto: Yes     No
Past 3 Years Number of:  
Accidents:           Citations:
Job Description and/or Relation:
Name:
Drivers License #:
State of License:
Date of Birth:
Furnished Auto: Yes     No
Past 3 Years Number of:  
Accidents:           Citations:
Job Description and/or Relation:
Name:
Drivers License #:
State of License:
Date of Birth:
Furnished Auto: Yes     No
Past 3 Years Number of:  
Accidents:           Citations:
Job Description and/or Relation:
Where do you purchase vehicles?
Who drives or tows vehicles to your lot?
How many times per year do you drive away more than 300 miles from point of purchase?
How many vehicles do you sell per year?
How many of those are on consignment?
What is your normal radius of operation?
What is your sales mix?  
a. Cars, Sport Utility, Pickups, Vans:     % d. Trucks, Tractors, Semi-Trailers     %
b. Motor Homes:     % e. Salvage Parts:     %
c. Travel Trailers, Camp Trailers:     % f. Other:     %
Describe your theft barriers (fence and gate or post and cable):
Describe your key controls:
How many dealer plates do you have?
Do you repossess vehicles? Yes     No
If yes, explain:
Do you sell "salvaged titled" vehicles? Yes     No
If yes, what percentage of vehicles require:  
Cosmetic Repair:    % Mechanical Repair:    % Structural Repair:    %
Do you always ride along on test drives? Yes     No
What percentage of your work is:  
Tune Up: %   Muffler: %
Transmission: %   Radiator: %
Brakes: %   Wheel Alignment: %
Sound System: %   Oil and Lube: %
Tires: %   Window Tint: %
Wash/Detail: %   Upholstery: %
Other: %   Other: %
Describe:
Do you sell gasoline? Yes     No
Or LPG? Yes     No
If yes, how many gallons?
Do you install trailer hitches? Yes     No
Do you have a spray paint booth? Yes     No
If yes, is it U/L approved? Yes     No
Is is ventilated? Yes     No
Do you recap tires or sell recapped tires? Yes     No
Do you tow for hire? Yes     No
If yes, explain:
Describe lot security and key controls:
Prior Carrier and Loss History for 3 Years
Current Carrier:
Policy Period:
Policy Premium:
Prior Carrier:
Policy Period:
Policy Premium:
Prior Carrier:
Policy Period:
Policy Premium:
Date of Loss:
Amount:
Description of Loss:
Date of Loss:
Amount:
Description of Loss:
Date of Loss:
Amount:
Description of Loss:
Coverage Requested
Garage Liability: $
Each Accident: $
Aggregate/Deductible: $
(Legal Liability) Garage Keepers: $ Per Location
SCL: $ Deductible
Collision: $ Deductible
Dealers Physical Damage: $ Per Location
SCL: $ Deductible
Collision: $ Deductible
Type: New     Used
Interests Covered: Owner     Owner and Creditor
Consignment Owner
Premises Medical Payments $1,000 Specifically Described Autos
Vehicle #:    Year:   Make:  
Body Type:    ACV:   V.I.N.: 
Vehicle #:    Year:   Make:  
Body Type:    ACV:   V.I.N.: 
Vehicle #:    Year:   Make:  
Body Type:    ACV:   V.I.N.: 
Vehicle #:   GVW:   Radius:  
Use:    Loss Payee:    
Vehicle #:   GVW:   Radius:  
Use:    Loss Payee:    
Vehicle #:   GVW:   Radius:  
Use:    Loss Payee:    
Uninsured Motorist: $
Personal Injury Protection: $
Fire Legal Liability: $ 50,000
BuyBacks:   
GK Transit Limit: $
Drive Away Miles $
Value Per Auto: $
Comments:
   

    

 
Workers Compensation Quote Form
Contact Person:
Email Address:
Daytime Phone:
Nature Of Business:
FEID#:
Number of covered employees:
Number of Owners:
Annual Remuneration Last Year:
Estimated Annual Remuneration Upcoming Year:
Gross Receipts For Year:
Loss Runs For Prior Years:
 

 
Employees To Be Insured
Employee #1
Last Name
First Name
Birth Date
SSN#
Duties
Employee #2
Last Name
First Name
Birth Date
SSN#
Duties
Employee #3
Last Name
First Name
Birth Date
SSN#
Duties
Employee #4
Last Name
First Name
Birth Date
SSN#
Duties
Employee #5
Last Name
First Name
Birth Date
SSN#
Duties
Certificate will be delivered as soon as information is verified.
 

    

 
Certificate of Insurance Request
Insured Information
Insured Name:
DBA or Business Name:
Policy Number:
Certificate Information:  
Certificate Holder Name:
Certificate Holder Street Address:
Certificate Holder Street Address:
Certificate Holder - City, State, Zip:
Certificate Holder Phone Numbers: Voice     Fax
Is certificate holder requesting to be named an additional insured? Yes     No
How do you want certificate delivered? Mail     Fax     Both

    

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