Association Insurance Programs

Indiana Restaurant Association Business Insurance Quote Request

Thank you for completing the Indiana Restaurant Association (IRA) quote request form. We will be in contact with you as soon as possible.

Are you an IRA member?

Contact Name:
BusinessName:
Address:
City:
State:
Zip:
Phone:
Email Address:
Website:
Tax ID:
Business Entity Type:

Currently Insured?

If yes name of carrier:
Date coverage needed:
Years of industry experience:
Year business started:
Description of business operations:
Restaurant type:

Fine Dining
Casual Dining
Franchise
Fast Food
Deli
Other
Receipts:
Food receipts:
Liquor receipts:
Catering receipts:
Delivery receipts:
Any Claims or Losses against the business in the last 5 years?

If Yes Please Describe:
Liability Limits desired:

Do you lease or own the space your office is in?

If owned please list the replacement cost value:
Business square footage:
Type of construction:

If other please describe:
Year built:
Building value:
Automatic extinguishing system?

Maintenance contract in place?

Value of your business property & equipment:
Value of the stock / inventory:
Do you have vehicles titled to or leased in the name of your company to be insured?

If yes list make model VIN # Deductible:
Workers Compensation:
Number of employees & total payroll:
Number of owners / officers & total payroll:

Comments:
Do not enter anything in this field: