Tell Us About Your CompanyCompany Legal Name*Business Structure*Sole ProprietorCorporationPartnershipLLCOther"Other" Business Structure:Number of Owners/Members/Partners*Add MembersMember NameOwnership %Option to Elect or Reject Workers' CompensationRemunerationMajority owner of other company/venture/business (yes/no) Company FEIN*Primary Business Contact* First Last Primary Contact Phone*Primary Contact Email* Mailing Address*Where would you like to receive mail? Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Tell Us About Your Jeremiah's Location(s)Number of Locations to be Insured?*1234 or moreLocation #1 DetailsPhysical Address of Location #1*What is the address of your Jeremiah's location? Same as Mailing Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code L1. Is this location currently insured?*YesNoL1. Is there a lender associated with this location?*YesNoL1. Is this location currently open?*YesNoL1. Actual Opening Date:* MM slash DD slash YYYY L1. Projected Opening Date:* MM slash DD slash YYYY L1. Is This Location Owned or Leased:*Owned BuildingLeased SpaceL1. Building Size:*Total square footage of the owned buildingL1. Leased Space Size:*The total square footage of the leased premise.L1. Completed Build-Out Cost:*Total value of tenant improvements, including any TI allowance from landlord. Please do not include equipment, furniture, or inventory.Location #2 DetailsPhysical Address of Location #2*What is the address of your Jeremiah's location? Same as Mailing Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code L2. Is this location currently insured?*YesNoL2. Is there a lender associated with this location?*YesNoL2. Is this location currently open?*YesNoL2. Actual Opening Date:* MM slash DD slash YYYY L2. Projected Opening Date:* MM slash DD slash YYYY L2. Is This Location Owned or Leased:*Owned BuildingLeased SpaceL2. Building Size:*Total square footage of the owned buildingL2. Leased Space Size:*The total square footage of the leased premise.L2. Completed Build-Out Cost:*Total value of tenant improvements, including any TI allowance from landlord. Please do not include equipment, furniture, or inventory.Location #3 DetailsPhysical Address of Location #3*What is the address of your Jeremiah's location? Same as Mailing Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code L3. Is this location currently open?*YesNoL3. Is this location currently insured?*YesNoL3. Is there a lender associated with this location?*YesNoL3. Actual Opening Date:* MM slash DD slash YYYY L3. Projected Opening Date:* MM slash DD slash YYYY L3. Is This Location Owned or Leased:*Owned BuildingLeased SpaceL3. Building Size:*Total square footage of the owned buildingL3. Leased Space Size:*The total square footage of the leased premise.L3. Completed Build-Out Cost:*Total value of tenant improvements, including any TI allowance from landlord. Please do not include equipment, furniture, or inventory. Tell Us About Your OperationsEstimated Business Personal Property Value L#1*Total value of all equipment, furniture, and stock at this location.Estimated Business Personal Property Value L#2*Total value of all equipment, furniture, and stock at this location.Estimated Business Personal Property Value L#3*Total value of all equipment, furniture, and stock at this location.Full Time Employees L#1*Please list the number of full-time employees for location # 1.Full Time Employees L#2*Please list the number of full-time employees for location # 2.Full Time Employees L#3*Please list the number of full-time employees for location # 3.Part Time Employees L#1*Please list the number of part-time employees for location # 1.Part Time Employees L#2*Please list the number of part-time employees for location # 2.Part Time Employees L#3*Please list the number of part-time employees for location # 3.Annual Payroll (Actual or Proforma Projection) L#1*Annual Payroll (Actual or Proforma Projection) L#2*Annual Payroll (Actual or Proforma Projection) L#3*Gross Annual Revenue (Actual or Proforma Projection) L#1*Gross Annual Revenue (Actual or Proforma Projection) L#2*Gross Annual Revenue (Actual or Proforma Projection) L#3*Will A Vehicle Be Owned In The Name Of Your Company or Used Regularly in Your Operations?*YesNoSection BreakCurrent Policy Information Drop files here or Select files Max. file size: 98 MB. Please upload current policy declarations pages.Currently Valued Loss Runs Drop files here or Select files Max. file size: 98 MB. Please upload currently valued loss runs for the prior 3 years for Workers' Compensation, General Liability, Auto, Property, and Umbrella policies.