Restaurant / Franchise Application

General Information:

Full Legal Name of Business *

How many locations do you own/operate? *

Contact Name *

Phone Number *

Federal ID Number *

Mailing Address *

Email Address *

Website *

Date of Ownership & Opening *

Hours of Operation *

Building Information:

Sq. Footage *

Year Built *

Construction type of building (pick one below) *

Wood FrameMasonryConcrete BlockConcrete TiltOther

Updates to Building:

Roof, Heating, Electrical, Plumbing *

Limit for Business Personal Property *

Limit for Business Income *

Projected Annual gross receipts *

Current Umbrella Limit *

Expiration date on Package, Employment Practice Liability and Workers Compensation *

Current insurance company for all lines of coverage *

Workers’ Compensation:

Owner 1

Name *

Title *

Ownership Percentage (%) *

Owner 2

Name

Title

Ownership Percentage (%)

Please indicate if any owner would like to be excluded *

Projected Annual Payroll for each class code *

Current number of full time employees *

Current Number of part time employees *

Loss Run Requirements:

Please provide currently valued copy of 5 years loss run history for all current in force policies (General Liability, Property, Workers’
Compensation, Employment Practices Liability and Auto). Provide loss runs for period of ownership if less than 5 years.

If any parties, such as landlords, require additional insured status, please provide us with the specific requirements.