ECG Commercial Insurance Quote Questionnaire
Insured Name (Company Name) *
Email *
Insured Address: *
Location Address *
Phone number
Date Business was Established *
FEIN / or SS #: *
Company *
Description of Business: *
Overall Policy Questions:
Renewal Date of Current Policy: *
Carrier *
Current Coverage *
Total Annual Premium (for all coverages):
General Liability
Total Annual Revenue:
% of Liquor Sales?
% of catering sales?
Total Number of Employees: *
Annual Payroll: *
Is it a per claim or per occurrence coverage? *
Property Section
Do you own the building?
Clear selection
If so, what is the building value?
What year was the building built?
Square Footage?
Are there other occupants in building?
Clear selection
Any building updates/improvements (if so, when and what)?
Total value of all contents (kitchen equipment, furniture, etc.)?
Are all kitchen equipment equipped with UL approved chemical extinguishing/cleaning systems?
Clear selection
Are they Wet or Dry?
Clear selection
Do you have an alarm system?
Clear selection
Alarm Company
What is the Property Deductible?
Coinsurance %?
Does your policy currently provide business income and extra expense to protect your revenue if business were to close ?
Clear selection
Business Auto
Please add the year, make, model, VIN number, and Leased or Own.
Auto 1#
Auto 2#
Auto 3#
Auto 4#
Auto 5#
Driver Information
Please add the driver name, Driver license, year first licensed,State, any violations (36 months)and what vehicle.
Driver 1#
Driver 2#
Driver 3#
Driver 4#
Driver 5#
Current Auto Limits:
Current Auto Deductible:
Current Auto Premium:
Current Auto Carrier:
Do you need to setup an appointment?
Clear selection
Type of Appointment
Clear selection
ECG Partner or Associate
Please visit our website at
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy