Restaurant / Franchise Application

Thank you for your interest in the ASURA Food and Retail Insurance Program. The limits and coverages are designed to meet the specific needs of your industry.

Please complete the questionnaire below as completely as possible, and if you have any questions please contact us. If you would prefer to complete and submit a hard copy application, please contact Bill Roberts at wroberts@asurarisk.com or call (925) 701-3080 We look forward to working with you.

General Information:

Building Information:

Construction type of building (pick one below) *

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.