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Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Business Information
Full Legal Business Name
Optional
DBA
Optional
Entity
Optional
Federal ID #
Optional
First Name
Required
Last Name
Required
Street
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City
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State
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ZIP / Postal Code
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Primary Phone Number
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Fax Number
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E-Mail Address
Required
Type of Restaurant
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Number Owners or Officers
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Number of Full Time Employees
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Number of Part Time Employees
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Estimated Monthly Payroll
Optional
Number of Locations
Optional
Years at present location
Optional
Years in Business
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Gross Annual Sales
Optional
Do you deliver?
Optional
If you provide entertainment describe types
Optional
If Alcohol Sales
TAMS or TIPS certified?
Optional
Liquor License Class & Number
Optional
Name on Liquor License
Optional
Any Liquor Violations?
Optional
If You Cater
Do you use someone else's kitchen?
Optional
Do you prepare food on site?
Optional
Do you use your personal vehicle(s)?
Optional
Do you have a cargo van insured for commercial use?
Optional
Do you review employees who drive his/her motor vehicle report annually?
Optional
Do you serve alcohol?
Optional
Building Information
Approx. Year Built
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Total Est. Square Footage
Optional
Your Occupied Square Footage
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Do you own the building?
Optional
Is the building free standing?
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Is building located in a shopping center?
Optional
Do you have a free standing sign?
Optional
More than 1 free standing sign?
Optional
Indoor Fire Spinkler
Optional
Building Construction
Optional
Hood Inspection Co. & Frequency
Optional
Hood Duct Cleaning Co. & Frequency
Optional
Did you make improvements?
Optional
Contents/Equipment Limit
Optional
Food Spoilage Limit
Optional
Sign Limit
Optional
Current Insurance
Current Carrier Name
Optional
Current Policy Expiration
Optional
/ /
Prior/Current Policy Carrier
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Do you know your worker compensationexperience mod?
Optional
Premium Amount
Optional
Coverage Description
Optional
Losses
Number of Losses Claimed
Optional
Additional Information
Agent Name (Optional)
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How Did You Hear About Us ?
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Preferred Contact Method
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Additional Comments
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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1802 S Parrott Ave
Okeechobee, FL 34974
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877.763.6625
info@pritchardsinc.com
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