Restaurant Florida Insurance Quote

Contact Information

First name ✶

Last name ✶

Phone ✶

Email ✶

Title ✶

Date of birth ✶

Co-Owner

Name

Relationship

Date of birth

Business Information

Business Name ✶

FEIN

Years in Business ✶

Legal Entity ✶

Annual revenue ✶

Location

Street address ✶

City ✶

State ✶

ZIP ✶

Employees

# Owners/Partners ✶

# Full-time Employees ✶

# Part-time Employees ✶

# Sub-contractors ✶

Estimated annual payroll ✶

$

Description of operations ✶

Insurance History

Claims History

Any claims in the past 5 years?

Yes

No

Claim Documentation

Please attach loss runs from the current insurance company for the last 5 years. You can also email them to email them to membersinsurancecentercommercial [at] floridamic [dot] org.

Any of the following in the last 10 years ✶

Bankruptcy

Repossession

Felony Conviction

None of the above

Current Insurance

Currently insured?

Yes

No

Current Insurance Policy

Insurance company

Policy expiration

Coverage amount

$

Current Policy

You can also email your policy to mail your current policy to us at miccommercial [at] floridamic [dot] org

Comments or questions

I understand that coverage cannot be bound or altered until the information has been confirmed by one of our representatives by phone or email. ✶

RESTAURANT INSURANCE QUOTE

Contact Information

Business Information

Insurance History

Desired Insurance Coverage