Mike Humphrey Larry Wayman A.W. (Bill) Bailey, Jr. Wes Bailey George Kidwell
Please complete and submit the form below, or click here to download a printable version, which you can complete and fax to (254) 753-1132.
Young Chefs Franchise
Request To Bind Insurance Coverage
To: Bailey Insurance &Financial Services, Waco, Texas
 (List the name of Individuals or Entity that will own the franchise):

 Mailing Address:

 Physical Address (if different):

 Contact Person:

 Telephone No:

 Fax No:


Please bind the insurance coverages as specifically quoted and identified in your proposal to us. We need coverage to begin:
*We suggest that the effective date of your insurance be no later than the date upon which you take possession of the premises.
Do you wish to purchase Employment Practice Liability Coverage? YES  NO
Do you wish to purchase Hired and Non-Owned Auto Coverage? YES  NO
Do you have any franchise owned vehicles you want to insure? YES  NO
Do you wish to add Employee Benefits Liability? YES  NO
Do you want Workers Compensation Insurance? YES  NO
Are there any other coverages (perhaps even identified in the Proposal Conclusion) that you wish to purchase? YES  NO
In order to bind coverage, please fax this completed form to (254) 753-1132
Or you can e-mail the completed form to bailey@baileyinsurance.com
Should you have any questions, please call (254) 753-5317
Should you wish to complete and submit this form on-line, please visit our website at www.baileyinsurance.com
Note: Completing this form comfirms your intent to bind coverage, but coverage will not be bound until you receive a written binder.