Client intake

Tell us about your operation.

Share the details of your restaurant so we can prepare a more useful coverage conversation.

Independent neighborhood restaurant exterior at dusk

E&A Insurance Group

Let’s get the details right.

847-651-3834
tom@eaigroup.net
316 W Northwest Hwy, Barrington, IL 60010

Fill in what you know and leave the rest blank. Fields marked with * are required.

Business information

Legal business name *

DBA or restaurant name

Business entity

Year business started

Years under current owner

Type of restaurant

Website

Contact information

Contact first name

Contact last name

Title or role

Phone *

Email *

Secondary phone

Secondary email

Best way to reach you

Location

Street address *

Suite or unit

City *

State *

Postal code *

Number of locations

Do you own or lease the building?

Building details

Include landlord name if leased, square footage, year built, construction type, and number of stories.

Operations and safety

Operations and financials

Include annual sales, payroll, food and alcohol sales mix, employee count, seating, hours, delivery, catering, entertainment, security, gaming, and patio seating.

Kitchen and safety

Tell us about commercial cooking, fryers, hood and Ansul protection, hood cleaning, sprinkler and alarm systems, and security cameras.

Coverage and current insurance

Coverage needed

List the coverage you would like quoted, such as general liability, property, liquor liability, workers’ compensation, business income, auto, umbrella, EPLI, cyber, spoilage, equipment breakdown, or hired and non-owned auto.

Contents or equipment value

Tenant improvements value

Building value, if owned

Current insurance

Include whether you are currently insured, carrier, agent or agency, annual premium, renewal date, date coverage is needed, non-renewal or cancellation history, and workers’ compensation expiration.

Claims history, last 5 years

If applicable, include the date, type of claim, and amount paid.

Notes or questions

Authorization

I confirm this information is accurate to the best of my knowledge and authorize E&A Insurance Group to use it to obtain insurance quotes on my behalf. Completing this form does not bind coverage.

Your name *

Date *