Insurance Quick Quote Indication

Restaurants

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Your Name:
Business Name:
Address:
Address continued:
City:	State: Zip Code:
Email Address:
Business Phone:	Home Phone:
Mobile Phone:	Fax:

Information About Your Restaurant

Number of years in business:
Description of your Restaurant:
Value of Building: $
Value of Contents:
Total Square Feet:
Square Footage of Dining Area:
Year Built:
Value of Food in Storage: $
Do you own or rent the building?	Own Rent

If OWN, do you rent to others?	Yes No

If YES, how many square feet?

Is there a basement?	Yes No
Were improvements made to the building?	Yes No

If YES, please describe what and when:

Distance from the nearest building:
- Right:
- Left:
- Rear:

Alarm Systems

Do you have an alarm system?	Yes No

If YES, is it centrally monitored?	Yes No

If YES, who is the alarm company?

Do you have a fire alarm?	Yes No

If YES, who maintains it?

Rating Information

Annual Gross Receipts: $
Gross Sales from Food: $

Do you serve Alcohol?	Yes No

If YES, Gross Sales from Alcohol: $

Annual Payroll: $

Coverage Information

Desired Deductible: $
Current Insurance Carrier:
Current Policy Number:
Current Policy Expiration Date:

Comments, Priority, Terms of Use

Comments or Additional Info:

Please Prioritize Your Request:	Hurry! I need it ASAP! Please quote prior to my renewal No hurry, just checking

By submitting this quick quote application, you declare that the information you are providing is accurate and complete to the best of your knowledge and belief. AMIS/Alliance Marketing & Insurance Services does not warrant or guarantee suitability or adequacy of coverage in meeting any generic, specific or contractual requirements of any insurance company, state, county, corporation, public entity, or public party that you may provide services to during the policy period, including any written or oral request forwarded to AMIS or its staff. You assume the risk of obtaining suitable or adequate coverage to meet any generic, specific or contractual requirements of your client or company. The information contained herein is provided with the understanding the AMIS is not engaged in rendering legal services, including legal opinions or advice, or professional risk management consulting. If legal services or professional services are required, you will need to seek the advice of legal counsel.

You agree:	Yes NoNOTE: This constitutes a digital signature.

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NOTE: An application or information form is not an insurance policy and does not bind any coverage. All applications must be underwritten and a quotation will be issued subject to underwriting guidelines. The quotation does not bind coverage.