Franchise
Association
Member
Program

New Franchise or Association Member Program 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 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:
MM slash DD slash YYYY
Location Information by Store #
Location Information by Store #
Store Number: Address 1: Address 2: City: State: Zip:
Building Type by Store #
Store Number: What Type of Construction? Sprinklered? Square Footage: Year Built:
Coverage/Rating Information by Store #
Store Number Annual Sales Building Value (if owned) Contents Value Where Are You?
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?
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
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?
Comments
Additional Information:
* indicates required fields
*
- I verify that this information is correct, to the best of my knowledge.
Consent*
I have read and understand the following disclaimer.
Please note completion of any request(s) for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting a request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company.

Let us assist you in developing the insurance solution that fits your establishment.

Store Number:	What Type of Construction?	Sprinklered?	Square Footage:	Year Built:

Store Number	Annual Sales	Building Value (if owned)	Contents Value	Where Are You?

Store Number	Hours of Operation Mon - Fri	Hours of Operation Sat - Sun	Drive-Thru Hours	Alarm System?	Central Alarm?	Alarm Certificate?	Alarm Manufacturer?

Names of Partners/Corporate Officers	Title/Relationship	Included or Excluded from Workers Compensation

Store Number:	Address 1:	Address 2:	City:	State:	Zip:

Franchise Association Member Program

New Franchise or Association Member Program Application

Insurance Policy Information

Location Information by Store #

Building Type by Store #

Coverage/Rating Information by Store #

Underwriting Information by Store#

Delivery/Catering Exposure

Automobile Exposure

Additional Underwriting Information

Liquor Liability Exposure

Workers' Compensation

Partners/Officers

Group Life & Health Coverage

Comments

Franchise
Association
Member
Program