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On-Line Restaurant & Hotel
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!

Your Name/Restaurant Name:  
Description (Hotel, Motel, Restaurant, etc.):  
Contact Phone Number:  
Your E-Mail Address:  
Confirm E-mail Address Again:  
Street Address:  
City:  
State:  
Zipcode:  
Restaurant Type:  
Current Insurance Company:  
Renewal Date:  
Current Cost:  
Any Claims in the Last 3 Years?  
Liquor Liability Included in Current Coverage?  
Building Coverage:  
Age of Building:  
Business Property Amount:  
Ansul Type:  
Deductible:  
Catering?  
Patio?  
Live Music?  
DJ?  
Total Square Footage:  
If hotel/motel, # of rooms:  
Public Access Sq. Ft.:  
Approximate Gross Sales:  
Food Sale %:  
Alcohol Sale %:  
Number of Employees:  

 
Thank you for filling out this form COMPLETELY!

DISCLOSURE "In connection with this application for insurance, some carriers may review your credit report, or obtain or use a credit based insurance score based on the information contained in that report. We may use a third party in connection with development of your insurance score."

CHECK THIS BOX FOR QUOTE RELEASE - This information has been reviewed with the customer and agreed upon. We value your privacy and will release NO personal information you give us to ANY other party, at any time, and make every effort to keep your information confidential.

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WE REPRESENT THE NATION'S FINEST INSURANCE CARRIERS
& SHOP MULTIPLE COMPANIES TO GET YOU THE BEST VALUE AND COVERAGE!

All United Insurance Agency represents the following insurance companies


Our Office Locations & Contact Information:

All United Insurance Agency, LLC | 990 South 2nd Street, Suite 4 | Ronkonkoma, NY 11779
Phone: 866-484-8656 | Fax: 866-362-9807

All United Insurance Agency, LLC | 13860 Ballantyne Corporate Place, Suite 120 | Charlotte, NC 28277
Phone: 866-484-8656 | Fax: 866-362-9807

Email: quotes@allunitedinsurance.com | About Us | Policy Service Request | Privacy Notice



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