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	By filling out the following questionnaire, you will enable us give you the most competitive rates available in the market today.
Corporate Name: (*)	Invalid Input
Federal ID#: (*)	Invalid Input
Name of Business: (*)	Invalid Input
UnEmp ID#:	Invalid Input
Address	Invalid Input
Contact Person: (*)	Invalid Input
County:	Invalid Input
Telephone:	Invalid Input
Fax:	Invalid Input
Web Site:	Invalid Input
E-mail: (*)	Invalid Input
Years experience in management:	Invalid Input
Years of ownership:	Invalid Input
	Building Information: Location 1
Building Amount of Insured Value	Invalid Input
Business Income:	Invalid Input
Contents:	Invalid Input
Deductible:	Invalid Input
# of Stories:	Invalid Input
# of Units:	Invalid Input
Total Sq Footage of Building:	Invalid Input
Rest Area Sq Footage:	Invalid Input
Bar Area Sq Footage:	Invalid Input
Seating Capacity Sq Footage:	Invalid Input
Type of Construction:	Invalid Input
Year Built:	Invalid Input
If older than 20 year, the dates of any renovations:	Invalid Input
Swimming Pool	Invalid Input
Waterslide:	Invalid Input
If yes, how high?	Invalid Input
Sprinklers	Invalid Input
Lifeguards:	Invalid Input
Waterslide Hours:	Invalid Input
Alarm System:	Invalid Input
Alarm System Type:	Invalid Input
Safe:	Invalid Input
Safe type:	Invalid Input
Bank deposits taken daily:	Invalid Input
Restaurant on premises:	Invalid Input
Dance floor:	Invalid Input
Is liquor served:	Invalid Input
Do you have happy hour:	Invalid Input
Happy hour times and types:	Invalid Input
Sign coverage:	Invalid Input
Money & Securities on premises:	Invalid Input
Money & Securities off premises:	Invalid Input
Employee dishonesty:	Invalid Input
	Automobile Insurance Information: Attach Vehicle List and Drivers License Numbers
Bodily Injury & Property Damage:	Invalid Input
Property Damage Limit:	Invalid Input
Uniinsured Motorist:	Invalid Input
Underinsured Motorists:	Invalid Input
Comprehensive Deductible:	Invalid Input
Collision Deductible:	Invalid Input
Hired & Non-owned:	Invalid Input
	Gross Sales
Lodging Sales:	Invalid Input
# of Rooms:	Invalid Input
Occup. Rate:	Invalid Input
Average daily room rate:	Invalid Input
Food sales:	Invalid Input
Liquor sales:	Invalid Input
	Workers Compensation Payroll
How many full-time employees do you have?	Invalid Input
How many halfl-time employees do you have?	Invalid Input
How many are Clerical/ Front Desk, Mgrs (Class Code 8810)?)	Invalid Input
How many are Hotel All Other (Class Code 9052)?)	Invalid Input
How many are Hotel/ Restaurant (Class Code 9058)?)	Invalid Input
Average Weekly Wage:	Invalid Input
Do you offer health insurance:	Invalid Input
Amount of Liability Coverage on current policy:	Invalid Input
Amount of Umbrella Coverage on current policy:	Invalid Input
	Package Policy
Name of Current Carrier:	Invalid Input
Premium:	Invalid Input
Renewal Date:	Invalid Input
	Workers Comp
Name of Current Carrier:	Invalid Input
Premium:	Invalid Input
Renewal Date:	Invalid Input
	Liquor Liability
Name of Current Carrier:	Invalid Input
Premium:	Invalid Input
Renewal Date:	Invalid Input
Have you had any losses in the past 3 years?	Invalid Input
If yes, please describe:	Invalid Input
	I must have a 3 year loss history on the package and the work comp. Please allow 30 to 60 days for rates. (Rush rates can be given if needed)

Auto Insurance, Condo Insurance, Homeowners insurance – CacciatoreInsurance.com - Illinois / Indiana / Chicago

Building Information: Location 1

Automobile Insurance Information: Attach Vehicle List and Drivers License Numbers

Gross Sales

Workers Compensation Payroll

Package Policy

Workers Comp

Liquor Liability

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