Gold  Standard  Insurance  Questionnaire  

 

     

Please  complete  and  return  to:     LH  Brenner  Insurance     [email protected]     Fax:  800-­‐894-­‐1758    

 

   

   

  Owner  (Individual  Name):      

 

Company  Name:       Mailing  Address:      

 

 

Phone  Number:      

 

Fax  Number:      

       

Current  Insurance  Broker:      

 

Email  Address:      

Current  Insurance  Carrier:      

   

Expiration  Date:      

Federal  Employer  ID  Number:                                                                                                                   _                   Years  of  experience  with  SUBWAY®:        

Best  Time  to  Call      

 

 

 

 

 

     

I  acknowledge  that  the  Operations  Manual  as  well  as  the  Gold  Standard  Insurance  Program  requires  that  I  purchase  certain  minimum  limits  of   liability  and  property  insurance.  Under  the  terms  of   the   program,   I   am   not   required   to   purchase   any   particular   level   of   additional   coverage   but,   instead   must   seek   a   level   of  protection  based  on  the  geographic  location,  size,  sales  volume,  value  of  contents  and  any  other   attributes  that  are  specific  to  my  business  operations.   Further,  I  have  read  the  terms  of  my  lease  and  understand  my  landlord  may  have  insurance  requirements  not  necessarily  satisfied  by  the  Gold   Standard  Insurance  Program.  It  is  my  responsibility  to  ensure  that  the  terms  of  my  lease  including  specified  insurance  coverage      and  limits   are  satisfied.  By  submitting  a  request  for  a  quote,  I  understand  that  it  is  my  responsibility  to  discuss  these  matters   with  my  insurance  broker.   I  authorize  my  insurance  broker  to  release  loss  history  information  for  the  purpose  of  procuring  accurate   quotations.   I  understand  data  will  be  used  in  conjunction  with  that  of  all  other  participating  franchisees  for  the  purposes  of  identifying  loss  trends,  risks  and   exposures.  I  understand  this  information  will  be  used  to  develop  and  maintain  risk  management  practices  and  to  achieve  the  most   favorable  pricing  system-­‐wide.   Additionally,  in  order  to  obtain  competitive  quotes  from  the  market  place,  you  are  authorizing  the  Gold  Standard  insurance  brokers   to  share   certain  information  with  incumbent  and  prospective  carriers,  including  but  not  limited  to:     ·∙               Name(s)  of  incumbent  insurer(s)  to  prospective  insurers   ·∙               Structure,  language  and  /  or  pricing  of  the  expiring  policy   ·∙               Name(s)  of  prospective  insurer(s)  to  prospective  insurers   ·∙               Specific  premium  or  premium  range   ·∙               Specific  priority  of  coverage  terms  as  outlined  by  client   ·∙               Aspects  of  a  competitor  quote  (including  price,  structure  and  /  or  policy  language)  to  a  prospective  insurer   ·∙               Allow  a  prospective  insurer  an  opportunity  to  submit  an  improved  quote  after  other  competing  quotes  have  been  disclosed   If   you   decline   or   wish   to   discuss   any   of   the   authorizations   listed   above   in   greater   detail,   please   contact   a   representative   at  each  of  the   Gold  Standard  brokers’  offices  at  the  time  you  submit  your  request.  

Name  /  Title     Signature     Date  

 

Gold  Standard  Insurance  Questionnaire  –  location  information  

 

 

RESTAURANT-­‐SPECIFIC  INFORMATION   Location  1  

 

Location  2  

Entity  Name  and  Complete  Address  

 

 

Year  Corporate  Entity  Established  

 

 

Store  Number  

 

 

Development  Agent  Name  

 

 

Gross  Sales  (per  year)  

 

 

Is  the  Store  open  24  Hours?  

 

 

Number  of  Employees  FT  /  PT  

 

 

Annual  Deli  Payroll  

 

 

Annual  Clerical  Payroll  

 

 

Current  Workers  Comp  Expiration  

 

 

Have  you  had  any  claims?  

 

 

Do  you  lease  this  building?  

 

 

If  yes,  landlord  address  

 

 

If  no,  building  value?  

 

 

Building  age  (year  built)  

 

 

Building  Type  (strip,  freestanding)  

 

 

Exposure  (retail,  mfg,  restaurant)  

 

 

Construction  Type  –  Brick  or  Frame  

 

 

Square  Footage  /  #  of  stories  

 

 

Updates?  (roof  /  plumbing  /  electrical)    

 

Building  Information  

Business  Personal  Property  Values   Equipment  –  including  furniture  

 

 

Build  Out  

 

 

 

 

Alarms  –  Yes  or  No  

 

 

Security  System  –  Yes  or  No  

 

 

Sprinkler  System  –  Yes  or  No  

 

 

Lender  Information   If  yes  -­‐  Name  /  Address  

Protective  Devices  

 

 

Gold  Standard  Insurance   Questionnaire  –  additional   locations   ESTAURANT-­‐SPECIFIC   INFORMATION  

       

Location  __  

Location  __  

Entity  Name  and  Complete  Address  

 

 

Year  Corporate  Entity  Established  

 

 

Store  Number  

 

 

Development  Agent  Name  

 

 

Gross  Sales  (per  year)  

 

 

Is  the  Store  open  24  Hours?  

 

 

Number  of  Employees  FT  /  PT  

 

 

Annual  Deli  Payroll  

 

 

Annual  Clerical  Payroll  

 

 

Current  Workers  Comp  Expiration  

 

 

Have  you  had  any  claims?  

 

 

Do  you  lease  this  building?  

 

 

If  yes,  landlord  address  

 

 

If  no,  building  value?  

 

 

Building  age  (year  built)  

 

 

Building  Type  (strip,  freestanding)  

 

 

Exposure  (retail,  mfg,  restaurant)  

 

 

Construction  Type  –  Brick  or  Frame  

 

 

Square  Footage  /  #  of  stories  

 

 

Updates?  (roof  /  plumbing  /  electrical)    

 

Building  Information  

Business  Personal  Property  Values   Equipment  –  including  furniture  

 

 

Build  Out  

 

 

 

 

Alarms  –  Yes  or  No  

 

 

Security  System  –  Yes  or  No  

 

 

Sprinkler  System  –  Yes  or  No  

 

 

Lender  Information   If  yes  -­‐  Name  /  Address  

Protective  Devices