New Franchise System Application
This form is designed to gather enough information to provide an acurate indication of the cost through the Corporate Approved Program. If you have more than four locations, please submit as many forms as necessary. Thank you.
Name and Address
Name of Insured - Your Corporate Name *
Contact Name *
Address 1 - For Correspondence / Billing: *
Address 2:
City: *
State: *
Zip: *
Phone: *
Fax:
Email Address:
Insurance Policy Information
Years Experience or years in Operation
# of Stores:
Current Insurance Company:
If this is a New Venture, what is anticipated opening date?
Current Umbrella Limit
Premium per Location:
Policy Expiration Date:
Location Information by Store #
Store Number: Address 1: Address 2: City: State: Zip:
1.
2.
3.
4.
Building Type by Store #
Store Number: What Type of Construction? Sprinklered? Square Footage: Year Built:
1. Frame Masonry
Non-Combustible Fire Resistive
Yes No
2. Frame Masonry
Non-Combustible Fire Resistive
Yes No
3. Frame Masonry
Non-Combustible Fire Resistive
Yes No
4. Frame Masonry
Non-Combustible Fire Resistive
Yes No
Coverage/Rating Information by Store #
Store Number Annual Sales Building Value (if owned) Contents Value Where Are You?
1. Free Standing Strip Mall Kiosk Within A Store
2. Free Standing Strip Mall Kiosk Within A Store
3. Free Standing Strip Mall Kiosk Within A Store
4. Free Standing Strip Mall Kiosk Within A Store
Underwriting Information by Store#
Store Number Hours of Operation Mon - Fri Hours of Operation Sat - Sun Drive-Thru Hours Alarm System? Central Alarm? Alarm Certificate? Alarm Manufacturer?
1. Yes No Yes No Yes No
2. Yes No Yes No Yes No
3. Yes No Yes No Yes No
4. Yes No Yes No Yes No
Delivery / Catering Exposure
Please complete this section if you do any delivery or catering.
Number of Deliveries per Month
What Percentage of Gross Sales is delivery?
Product delivered by? Employee Vehicle       Company Vehicle
Both
Automobile Exposure
Do you have any owned automobiles? Yes No
If yes, how many autos?
How many drivers?
Additional Underwriting Information
Do you check motor vehicle reports for all prospective hires? Yes No
Do you require employees to carry a minimum limit of auto liability? Yes No
If so, what is your minimum limit requirement?
Liquor Liability Exposure
Any Alcohol or Liquor Sales? * Yes No
What percentage of Gross Sales is from Alcohol/Liquor?
Workers' Compensation
Federal ID Number:
Annual Payroll:
Number of Full Time Employees:
Number of Part Time Employees:
Please provide your State Unemployment Tax Assessment Rate
Partners/Officers
Names of Partners/Corporate Officers Title/Relationship Included or Excluded from Workers Compensation
1. Included Excluded
2. Included Excluded
3. Included Excluded
4. Included Excluded
Group Life & Health Coverage
If interested, please complete this form and complete our franchise group life and health coverage census
Are you interested in obtaining Group Life and Health Coverage? Yes No
Comments
Additional Information:
* indicates required fields
I verify that this information is correct, to the best of my knowledge.