Restaurant Insurance Quote Request | First Insurance Agency of the Hill Country

For your protection and security, the information you provide is sent to us via a secured server. Please fill out this form as completely as possible to ensure an accurate request.

Complete the following information if you would like to obtain a Restaurant Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

Select Your State

Please Note: We only write insurance for these states.

Address

What is your address?

Street Address Address Line 2 City State ZIP Code

Name*

What is your name?

First Last

Business Name

What is your business name?

Telephone Number (Business)*

What is your business telepone number?

Telephone Number (Home)

What is your home telepone number?

Email Address*

What is your email address?

Fax

What is your fax number?

Property Information

Property Address

What is the Property Address?

Street Address Address Line 2 City State ZIP Code

Total Square Footage of Business Building

What is the total square footage of the building your business is in?

Please enter a number greater than or equal to 0.

Total Square Footage of Business Only

What is the total square footage of your business only?

Please enter a number greater than or equal to 0.

Square Footage of Customer Area

What is the square footage of the customer area only?

Please enter a number greater than or equal to 0.

Stories

How many stories is it?

Please enter a number from 0 to 99.

Ground Floor Square Footage

If two or more stories, what is the ground floor square footage?

Please enter a number greater than or equal to 0.

What is the construction type?

What type of roof covering?

Was the roof updated?

Yes
No

If yes, what year?

Year Roof Updated

Please enter a number from 1700 to 3000.

What is the distance of fire protection?

Brush

Is the business in a brush area?

Yes
No

Storage Area

Do you have a storage area more than 1500 Sq. Ft.?

Yes
No

Smoke Detectors

Are there smoke detectors at this location?

Yes
No

Smoke Alarm

Are there smoke alarms at this location?

Yes
No

Fire Extinguishers

Are there fire extinguishers?

Yes
No

Automatic Fire Sprinklers

Does the building have interior automatic fire sprinklers?

Yes
No

Fire Alarm

Is there a fire alarm?

Yes
No

Theft Alarm

Is there a theft alarm?

Yes
No

Deadbolts

Are there deadbolts on all doors?

Yes
No

Circuit Breakers

Are there circuit breakers?

Yes
No

Is the electrical updated?

Electrical Update

Thermostatically Controlled

Is the heading/ air conditioning thermostatically controlled?

Yes
No

Central

Is the heating/ air conditioning central?

Yes
No

Plumbing Updated

Has the plumbing been updated?

Yes
No

If yes, what year was the plumbing updated?

Year Plumbing Updated

Please enter a number from 1700 to 3000.

Parking Protection

Is the parking lot under your protection?

Yes
No

Underwriting Information

Nature of Business

What is the nature of your business?

Number of Owners

How many owners?

Please enter a number greater than or equal to 0.

Number of Employees

How many Employees

Please enter a number greater than or equal to 0.

Payroll of owners

What is the payroll amount of the owners?

Payroll of employees

What is the payroll amount of the employees?

Total Annual Gross Receipts

What is the total annual gross?

Hard Liquor Receipts

What are the total annual hard liquor receipts?

Beer and Wine Receipts

What are the total annual beer and wine receipts?

Food Receipts

What are the total annual food gross receipts?

Business License Number

What is the business license number?

License Type

What is the license type?

Years of Experience

Years of experience in this business?

Please enter a number greater than or equal to 0.

Years Operated

How many years have you operated this business?

Please enter a number greater than or equal to 0.

Open 24 hours

Is this business open 24 hours a day?

Yes
No

Propane Tank Filling

Is there filling of propane tanks?

Yes
No

Unusual Exposures

Please describe the nature of your business and ANY unusual exposures.

Entertainment Information

Is there entertainment?

Yes
No

If yes, please describe.

Is there live music?

Yes
No

If yes, what size is the dance floor and how many nights per week is there dancing?

Are there any coin operated amusement devices?

Yes
No

If yes, please describe.

Are there any pool tables?

Yes
No

If yes, how many and are they coin operated?

Are there any bouncers, doormen, ID checkers, armed or security guards?

Yes
No

If yes, how many of each? (list their job duties and employer)

Are there any audience participation events?

Yes
No

If yes, describe events.

Do you sponsor any sporting events?

Yes
No

If yes, describe events.

Do you have any other type of entertainment?

Yes
No

If yes, describe events.

Cooking Information

Describe the cooking devices at your business.

Tableside Cooking

Is there tableside cooking?

Yes
No

Automatic Suppression System

Is there an automatic suppression system?

Yes
No

If yes, do they protect all hoods, ducts and griddles?

Yes
No

Deep Frying

Is there any deep frying?

Yes
No

If yes, is there a high limit shutoff?

Yes
No

Outside Cleaning Service

Do you have an outside cleaning service for the hoods and duct system?

Yes
No

How Often Cleaned

How often are hood and duct cleaned?

Manufacturing

Is there any manufacturing, mixing, re-labeling or repackaging of products?

Yes
No

Delivery Service

Is there any delivery service?

Yes
No

Catering Service

Is there any catering service?

Yes
No

Claims and Miscellaneous Information

Losses – Claims

Were there any losses or claims in the last 5 years?

Yes
No

If yes, what is the date, amount paid and description of each loss or claim?

What is the current insurance company?

Amount Current Coverage

How much are you paying now?

Renewal Date

What is the renewal date?

Insurance Cancelled

Has insurance ever been cancelled?

Yes
No

If yes, describe.

Regulatory Violations or Citations

Have you ever had regulatory violations or citations?

Yes
No

If yes, describe.

Employees Trained

Are employees trained on how to handle minors or intoxicated customers?

Yes
No

If yes, describe.

Coverage Information

Building Coverage

What building coverage is requested?

Other Structures Coverage

What other structures is requested?

Business Contents Coverage

What business contents is requested?

Loss of Use Coverage

What is the loss of use coverage requested?

Liability Limits

What is the liability limits requested?

Policy Deductible

What policy deductible is requested?

Questions, Comments or Additional Coverage

Are there any questions, comments or additional coverage required?

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