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On-Line Restaurant
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Name/Restaurant Name:  
Contact Phone Number:  
Your E-Mail Address:  
Confirm E-mail Address Again:  
Street Address:  
City:  
State:  
Zipcode:  
Restaurant Type:  
Current Insurance Company:  
Renewal Date:  
Current Cost:  
Any Claims in the Last 3 Years?  
Liquor Liability Included in Current Coverage?  
Building Coverage:  
Age of Building:  
Business Property Amount:  
Ansul Type:  
Deductible:  
Catering?  
Patio?  
Live Music?  
DJ?  
Total Square Footage:  
Public Access Sq. Ft.:  
Approximate Gross Sales:  
Food Sale %:  
Alcohol Sale %:  
Number of Employees:  

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Insurance Resources & Services, Inc. | 425 - 23rd Avenue S., Suite A206 | Seattle, WA 98144
Phone: 206-728-1757 | Fax: 206-329-1649 | E-Mail us at: dlcason@msn.com

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