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  Your Company Information:
 
Name Of Business:
 
Year In Business:
 
Contact Name:
 
Phone:
 

Fax:
 

Email:
 
Location Address:
 
City:
 
State:
Zip:
     
  Current Insurance Company (Not Brokerage) :    No Prior Coverage
  Current Carrier:
  Type of Policy:
  Policy Exp. Date:
  Claims in Past 3 Yrs: Yes    No
     
  Property Information:  
 
  Building Interest: Own    Lease
  Construction of Building:
  Square Footage Occupied:
  Automatic Sprinkler System: Yes    No
  Central Station Burglar Alarm: Yes    No
  Business Personal Property value:
     
  Description of Operations:  
 
  Hours of Operation:
  Are You a Franchisee: Yes    No
  Do You Provide Live Entertainment: Yes    No
  Is There a Bar Inside Restaurant: Yes    No
  Is There Tabletop Cooking: Yes    No
  Restaurant Classification:
     
  Breakdown of Annual Sales:  
 
  Food:
  Alcohol:   N/A
  Catering:   N/A
  Delivery:   N/A
     
  Workers Compensation Supplemental:  
 
  Federal Tax ID:
  Total # of Employees:
  Total # of Owners/Officers/Executives:
  Estimated Gross Annual Payroll:
  Are You a Member of the CRA: Yes    No
  Do You Provide a Blue Cross Group Health Plan: Yes    No
     
  How Did You Hear About Us:  
 
  How Did You Hear About Us:

 
 
 
Address: 1041 W. 18th Street, Suite A204, Costa Mesa, CA 92627 Phone: (800) 987-5051
Excelsure

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