Your Name/Restaurant Name:
Contact Phone Number:
Your E-Mail Address:
Confirm E-mail Address Again:
Location City, State and Zip Code (Must be in New York):
Restaurant Type:	Choose One Fine Dining Casual Pizza (Delivery) Pizza (No Delivery) Fast Food Bar / Tavern (Food) Bar / Tavern (No Food) Nightclub (Live Entertainment) Nightclub (No Entertainment) Gentlemen's Club Other
Current Insurance Company:
Renewal Date:
Current Cost:
Any Claims in the Last 3 Years?	Choose One Yes No
Liquor Liability Included in Current Coverage?	Choose One Yes No
Building Coverage:	Choose One Own the Building Do NOT Own the Building
Age of Building:
Business Property Amount:
Ansul Type:
Deductible:
Catering?	Choose One Yes No
Patio?	Choose One Yes No
Live Music?	Choose One Yes No
DJ?	Choose One Yes No
Total Square Footage:
Public Access Sq. Ft.:
Approximate Gross Sales:
Food Sale %:
Alcohol Sale %:
Number of Employees: