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Restaurant Insurance Application
Please print and fax completed form to:
Gambill Insurance 828-696-3423
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Courthouse Square Building
P.O. Box 2240
Hendersonville, NC 28793
Phone (828) 692-9634
Fax (828) 696-3423
Email: emerals1@aol.com
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APPLICATION FOR RESTAURANT
Insured Name/ Business:
Mailing Address:
Location Address:
Federal I. D #:
Inspection Contact: Phone:
Applicant:
�� Individual �� Corporation �� Partnership �� LLC
Proposed effective date: ____ / ____ / ____
Description of operation:
Years in business: Years under current management:
Hours of operation from:
Number of employees: �� Full-time: �� Part-time:
Live entertainment: Describe:
Catering? Explain (i.e. weddings, functions):
Property Section
Location (1) (if there is more than one location fill out separate application)
Coverages / Limits needed:
Building: $ Contents: $
Deductible: $ Outdoor Sign: $
Property:
Construction: Year Built:
Square Footage: Protection Class:
Updates:
Roof: ___________ (year) Plumbing: _____________ (year)
Heat: ___________ (year) Electric: ______________ (year)
Liability Section
Total Receipts $ Food: $
Liquor: $
License Type: Number:
List previous carrier:
Company Name, Effective Dates, & Policy #:
Loss History (Last 5 yrs):
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