IDQ Companies Franchisee Insurance Program - Application
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For an accurate quotation, please complete this form in its entirety. If you prefer, call us at 1-800-428-8237 or click here to complete the contact form.

 
 
 
Business Information
Named Insured:
Email Address:
(optional)
Federal Tax ID:
(optional)
Entity:
(optional)		  Individual
 Partnership
 Corporation
 Other
Business Mailing Address
Street Address 1:
Street Address 2:
(optional)
City:
State / Province:
ZIP / Postal Code:
Country:
Work / Daytime Phone:
Work / Daytime Fax:
(optional)
Home / Evening Phone:
(optional)
Contact Preferences
Preferred Contact Time:
(optional)		  Morning
 Afternoon
 Evening
Preferred Contact Method:
(optional)		  Email
 Work / Daytime Phone
 Home / Evening Phone
Store Location
Location - Store Information
Store Number:
Store Type: Dairy Queen®/Brazier®
Dairy Queen®/Limited Brazier®
Dairy Queen® Soft Serve
Treat Center®
Orange Julius®
Karmelkorn®
Rating:  QVSC:   %
 Health Dept.: %
Estimated Sales: $
Location - Building Information
Bldg. Replacement Value: $
Contents Replacement Value: $
Section 1 Deductible: $
Year Built:
Square Footage: sq. ft.
Recent Updates:
Roof
Year Updated: 
Wiring / Electrical
Year Updated: 
Plumbing
Year Updated: 
Location - Workers Compensation Policy
% of Food Sales to All Sales: %
Estimated Annual Payroll:
Class Code:
(optional)
Experience Mod. Factor:
(optional)
Self Coverage:
(optional)

If your state permits you to elect not to be covered as the owner, officer or partner do you want to be included for Workers' Compensation Coverage?
Yes
No
Losses Last 3 Years:
(optional)
Location - Extinguishing System
U.L. Approved:
YES! I have a U.L. approved Automative Extinguising System
Maintenance Contract:
YES! I have a semi-annual maintenance contract for cleaning, testing, and maintenance of the system.
Service Contractor Name:
Last Service Date:
Location - Duct Exhaust System
U.L. Approved:
YES! I have a U.L. approved Duct Exhaust System.
Maintenance Contract:
YES! I have a semi-annual maintenance contract for cleaning, testing, and maintenance of the system.
Coverage:
YES! My Duct Exhaust System covers all cooking equipment.
Service Contractor Name:
Last Cleaning Date:
Cleaning Frequency:  Weekly
 Other
Type of Exhaust Filters:  Mesh
 Baffle
Location - Coverage Details
Additional Earnings Insurance:
YES! I want additional earnings insurance beyond $150,000 in the amount of:
$
Additional Earthquake Coverage:
YES! I want additional earthquake coverage beyond $25,000 in the amount of:
$
Surfaces and Parking:
YES! All interior and exterior walking surfaces and parking areas are in good condition.
Bank Deposits:
YES! I make daily bank deposits.
Cash Removal:
YES! I remove excess cash periodically during open hours and only opening cash at night.
In-store safe:
YES! I have a safe at this location with a class of:
Playground:
YES! I have a playground with the following equipment:
Location - Store Address
Street Address 1:
Street Address 2:
(optional)
City:
State:
ZIP Code:
Country:
Store Phone:
Store Fax:
(optional)
 



 

® T.M. Am.D.Q. Corp © 2007 Am.D.Q. Corp Mpls. MN
 
IDQ Companies Franchisee Insurance Program
Administered by Lockton Risk Services
800-428-8237