Jeremiah's Franchisee Questionnaire

Tell Us About Your Company
Company Legal Name*
Business Structure*
"Other" Business Structure:
Number of Owners/Members/Partners*

Add Members

Member Name	Ownership %	Option to Elect or Reject Workers' Compensation	Remuneration	Majority 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 ZIP Code

Tell Us About Your Jeremiah's Location(s)
Number of Locations to be Insured?*
Location #1 Details
Physical Address of Location #1*
What is the address of your Jeremiah's location?

Same as Mailing

Street Address Address Line 2 City State ZIP Code
L1. Is this location currently insured?*
L1. Is there a lender associated with this location?*
L1. Is this location currently open?*
L1. Actual Opening Date:*
MM slash DD slash YYYY
L1. Projected Opening Date:*
MM slash DD slash YYYY
L1. Is This Location Owned or Leased:*
L1. Building Size:*
Total square footage of the owned building
L1. 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 Details
Physical Address of Location #2*
What is the address of your Jeremiah's location?

Same as Mailing

Street Address Address Line 2 City State ZIP Code
L2. Is this location currently insured?*
L2. Is there a lender associated with this location?*
L2. Is this location currently open?*
L2. Actual Opening Date:*
MM slash DD slash YYYY
L2. Projected Opening Date:*
MM slash DD slash YYYY
L2. Is This Location Owned or Leased:*
L2. Building Size:*
Total square footage of the owned building
L2. 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 Details
Physical Address of Location #3*
What is the address of your Jeremiah's location?

Same as Mailing

Street Address Address Line 2 City State ZIP Code
L3. Is this location currently open?*
L3. Is this location currently insured?*
L3. Is there a lender associated with this location?*
L3. Actual Opening Date:*
MM slash DD slash YYYY
L3. Projected Opening Date:*
MM slash DD slash YYYY
L3. Is This Location Owned or Leased:*
L3. Building Size:*
Total square footage of the owned building
L3. 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 Operations
Estimated 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?*
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Current Policy Information
Drop files here or

Max. file size: 98 MB.
Please upload current policy declarations pages.
Currently Valued Loss Runs
Drop files here or

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.

Tell Us About Your Company

Tell Us About Your Jeremiah's Location(s)

Location #1 Details

Location #2 Details

Location #3 Details

Tell Us About Your Operations

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