On-Line Commercial Restaurant
Hotel/Motel Insurance Quote
Your Personal Data
    Your Name:
    Business Name:
    Property Address:
    City:
    *State:
    Zip/Postal:
    E-Mail (REQUIRED):
    Confirm E-Mail:
    Phone:
    Fax (optional):
 
Underwriting Information
 
    Federal Tax ID#:
    (Some carriers use credit history to qualify
    this information is REQUIRED)
 
    Date Coverage Needed:
 
    Prior Carrier:
 
    Describe Business:
 
    Gross Annual Receipts: $
 
    Describe any liquor sales:
 
    Describe any live entertainment:
 
    Describe food sales:
 
    Gross Annual Payroll: $
 
    Square Footage of
    Your Business Location:		 $
 
    Type of Buildings
    and year of construction:		 $
 
    If motel or hotel, how many units?
 
    What is average occupancy rate?
 
    Number of Employees:
 
    Tell us what kind of
    commercial coverage you
    are looking for, and why:
 
    Prior Claims? Yes No
    Describe claims in detail:
 
Limits & Coverages:
    Liability Limits: $100,000     $300,000
$500,000     $1 Million
 
    Building Coverage Needed?
    If so, list type and amount:
 
    Business Contents Needed?
    If so, list type and amount:
 
    Don't worry if you are not sure of coverage needed or other information. This
    preliminary form will allow us to approach the proper carriers and we will get other
    information from you as needed later.
 
    Comments/Remarks:
 
    Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone
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*Hawkins Insurance Group is licensed to sell in more than 20 states. If you are contacting us from a state in which we are not licensed, we will contact you to inform you that we cannot provide you with a quote.

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P.O. Box 100 103 South First Street, Edina, MO 63537

Phone 660.397.2251 Fax 660.397.2320

Copyright ©2010 Hawkins Insurance Group, Inc. All rights reserved.

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Garage/Dealer Insurance

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Restaurant/Hotel/Motel

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