About You / Your BusinessLegal Business Name*Legal Entity:*IndividualLLCCorporationPartnershipOtherMailing Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone:*Email:* Key Contact Name:* First Last Years of Industry Experience:*Year Business Established:*Description of Operations:*Hours of Operations:*Has there been any losses or insurance claims in the past 3 years?* Yes No Annual Estimated Alcohol Sales:*Annual Estimated Food Sales:*Location InformationAddress:* Same as previous Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Square Footage:*Replacement Value of Content:*computers, desks, etc.Replacement Value of Kitchen Equipment:*cooktops, deep fryers, freezers, etc.Replacement Value of Interior Buildout:*improvements & betterments, etc.Do you own the building?:* Yes No Is the building sprinklered?:* Yes No Do you employ security guards?:* Yes No Do you offer valet services?:* Yes No Employees# of Full Time Employees:*# of Part Time Employees:*Annual Payroll:*CoverageCoverage Start Date:* MM slash DD slash YYYY General Liability:*Excluded$1mil / $1mil$1mil / $2mil$2mil / $2mil$3mil / $3mil$4mil / $4mil$5mil / $5milCommercial Auto Liability:*Excluded$1mil / $1mil$1mil / $2mil$2mil / $2mil$3mil / $3mil$4mil / $4mil$5mil / $5milLiquor Liability:*ExcludedIncludedEmployment Practices Liability (EPLI):*ExcludedIncludedWorkers Compensation:*ExcludedIncludedGroup Health Insurance*ExcludedIncludedWould you like a quote for Employee Benefits? i.e. group health, disability, life insurance:* Yes No Preferred Broker*Select BrokerAlec RobertsNick PurselDanny ElisevichPete GybenJohn HartDaniel BanElizabeth BellNo PreferenceHow did you hear about us?:* Google Referral Yelp Other Who referred you?:*How?:CAPTCHA
