Applicant Name:

Mailing Address:
City / State / ZIP
Business Entity:  
Business Type:  
Location Address:
City / State / ZIP
Do You Own the Building Do You Lease the Space Number of Stores Sprinkler System
Square Footage of Operation Desired Business Personal Property Limit Building Age Number of Employees
Is Any Entertainment Provided? Annual / Receipts With Liquor Annual Sales / Receipts w/out Liquor Is There Valet Parking
Is There Any Off Premises Catering? Is Food Delivery Service Provided? What Are The Hours of Restaurant Operation?
Is There a UL Approved Automatic Extinguishing System?
Claims History (over the last 5 years)
Number of Claims Approximate Amount Paid Claim Details

To Submit Request:
-- Complete Form, Print then
 FAX to (415) 454-8311

Please Note: Our Agency Will Contact You Within the Next Business Day After Submitting REQUEST

Full-Service Insurance Agency
817 Mission Avenue - San Rafael - California 94901
Tele. (415) 454-0100 - FAX (415) 454-8311 - Toll Free (888) 822-4INS(4467)
California Insurance License 0541868