Restaurant Recovery Insurance

Broker Information

Broker Company Name:*

Broker Contact Name:*

Broker Phone Number:*

Broker Email:*

Confirm Broker Email:*

Application Information

Applicant:*

Mailing Address:*

City:*

State:*

Zip:*

Trade Name(s):*

Number of Locations:*

Business Type:*

Owned

Franchised

Restaurant Type:*

Fast Food

Casual Dining

Fine Dining

Buffet

Other

Estimated Food and Beverage Gross Annual Revenues:*

Estimated Food and Beverage Gross Annual Revenues Largest Location:*

Minimum Limits Required:*

Proposed Effective Date:*

Have you experienced either of the following within the last five (5) years?

Had a food borne illness / accidental malicious tampering incident?:*

Yes

No

Been cited or fined or closed by any public health authority or civil authority?:*

Yes

No

Upload Documents if any

Allowed file extensions: .rtf, .pdf, .doc, .docx, .txt, .xls, .xlsx, .jpe, .jpeg, .jpg, .gif, .png
Maximum file size: 4 MB.

Type the code shown:

*

I understand that this indication is subject to the receipt of a fully completed, signed and dated RRI application.

Submit Application