Restaurant Recovery Insurance

SHORT FORM PROPOSAL FOR INDICATION PURPOSES

Anticipated Effective Date: Click here to enter a date.

Owner: Click here to enter text._ Trade Name: Click here to enter text.

Address: Click here to enter text.

Total # of Locations: _Click here to enter text.

Owned: Click here to enter text.

Franchised: Click here to enter text.

Agent Name: Click here to enter text.

Agent Phone: Click here to enter text. Email: Click here to enter text.

Type: Fast Food ☐Casual Dining ☐Fine Dine ☐Buffet ☐Other ☐

Est. Gross Annual Revenues: $ Click here to enter text. Est. Largest Location: $ Click here to enter text.

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

Had a food borne illness / accidental malicious tampering incident?	Y ☐	N ☐

Been cited / fined or closed by any public health authority or civil authority?	Y ☐	N ☐

If YES to either of the above please describe: Click here to enter text.

NOTE: This indication is subject to receipt of a fully completed, signed and dated RRI application

Applicant's Signature: Click here to enter text._ Title: Click here to enter text.

Print Name: Click here to enter text. Date: Click here to enter a date.