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ECG Commercial Insurance Quote Questionnaire
* Indicates required question
Insured Name (Company Name)
*
Your answer
Email
*
Your answer
Insured Address:
*
Your answer
Location Address
*
Your answer
Phone number
Your answer
Date Business was Established
*
MM
/
DD
/
YYYY
Website
Your answer
FEIN / or SS #:
*
Your answer
Company
*
Indiv.
Partnership
Corporation
Other:
Description of Business:
*
Your answer
Overall Policy Questions:
Renewal Date of Current Policy:
*
MM
/
DD
/
YYYY
Carrier
*
Your answer
Current Coverage
*
General Liability
Property
Work Comp
Umbrella
Business Auto
Liquor Liability
Other:
Required
Total Annual Premium (for all coverages):
Your answer
General Liability
Total Annual Revenue:
Your answer
% of Liquor Sales?
Your answer
% of catering sales?
Your answer
Total Number of Employees:
*
Your answer
Annual Payroll:
*
Your answer
Is it a per claim or per occurrence coverage?
*
Your answer
Property Section
Do you own the building?
Yes
No
Clear selection
If so, what is the building value?
Your answer
What year was the building built?
MM
/
DD
/
YYYY
Square Footage?
Your answer
Are there other occupants in building?
Yes
No
Clear selection
Any building updates/improvements (if so, when and what)?
Your answer
Total value of all contents (kitchen equipment, furniture, etc.)?
Your answer
Are all kitchen equipment equipped with UL approved chemical extinguishing/cleaning systems?
Yes
No
Clear selection
Are they Wet or Dry?
Yes
No
Clear selection
Do you have an alarm system?
Yes
No
Clear selection
Alarm Company
Your answer
What is the Property Deductible?
Your answer
Coinsurance %?
Your answer
Does your policy currently provide business income and extra expense to protect your revenue if business were to close ?
Yes
No
Maybe
Clear selection
Business Auto
Please add the year, make, model, VIN number, and Leased or Own.
Auto 1#
Your answer
Auto 2#
Your answer
Auto 3#
Your answer
Auto 4#
Your answer
Auto 5#
Your answer
Driver Information
Please add the driver name, Driver license, year first licensed,State, any violations (36 months)and what vehicle.
Driver 1#
Your answer
Driver 2#
Your answer
Driver 3#
Your answer
Driver 4#
Your answer
Driver 5#
Your answer
Current Auto Limits:
Your answer
Current Auto Deductible:
Your answer
Current Auto Premium:
Your answer
Current Auto Carrier:
Your answer
Appointment
Do you need to setup an appointment?
Yes
No
Maybe
Clear selection
Type of Appointment
Telephone
In person (Visit
eedmond.appointy.com
)
Webinar/Video Conference
Other:
Clear selection
ECG Partner or Associate
Your answer
Comments
Your answer
Please visit our website at
www.consultwithedmond.com
.
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