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Home » Our Forms » Restaurant Program Online Application

Everyone’s insurance needs are different. Consider filling out our form and we’ll get back to you soon.

Get the restaurant insurance coverage for your needs.

Please complete the form to your best ability. Fields marked with an * are required.

"*" indicates required fields

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General Information

Business Name*

Federal Employee ID Number (FEIN)*

Mailing Address*

Street Address* City* State* ZIP Code*

Contact Person Name*

First Name* Last Name*

Email*

Phone Number*

Website Address

Total Annual Revenue*

Total Food Sales*

Liquor Sales*

Other Sales

Please explain Other

Total Payroll*

Workers Compensation Experience Mod (if known)*

Physical Location Information

Address*

Street Address* City* State* ZIP Code*

Do you own the building?*

Yes

Central fire alarm?*

Yes

Is building sprinklered?*

Yes

Central burglar alarm?*

Yes

Any other locations we need to insure? If so, please provide addresses

Business Operations

How would you describe your business? (use check boxes)*

Fast food or fast casual (typically counter service, no wait staff)

Family dining

Fine dining

Other

If other, please explain.

Hours of Operation*

Are you open after 12am and before 5am?*

Yes

Any amusement devises (pool table, darts, playgrounds) ?*

Yes

Do you offer live entertainment?*

Yes

Are you open seasonally? (less than 8 months per year)?*

Yes

Do you offer delivery services?*

Yes

Do you rent your facility for events?*

Yes

Is Kitchen Equipped with UL 300 automatic extinguishing system with a manual activator pull station?*

Yes

Hood and ventilations system professionally installed – NFPA 96 and serviced on a quarterly basis and with a baffle style filter (not mesh)?*

Yes

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Type of kitchen equipment used (mark all that apply)*

Yes

Do you serve any raw or uncooked food (i.e. sushi, oysters, etc)*

Yes

If alcohol is served are employees TIPS (alcohol awareness) trained?*

Yes

Applicant in compliance with all state requirements for the serving of alcohol?*

Yes

Property Coverage

Limit for Business Personal Property*

Current Insurance

Carrier Name*

Any Claims in last 5 years? If so, more information needed

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Maury Donnelly & Parr, Inc. is a professional insurance agency that is devoted to keeping our insured protected and providing them with insurance solutions for their needs. MDP strives to offer personalized levels of service in our niche programs as well as a wide range of insurance knowledge to write most classes of business, regardless of their size. Our goal is to provide insurance of the highest quality so every client may obtain coverage levels that are right for their unique situation and to always value coverage over policy price.

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