Commercial Insurance Quote Request
Tucker Insurance Agency, Inc.
Business Name:
Business Phone Number:
-
Area Code
Phone Number
Business Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Email:
example@example.com
Date Business Started:
Type (sole proprietor. LLC, LLP, Corp):
FEIN:
Contact Name:
Contact Title:
Contact Phone Number:
-
Area Code
Phone Number
Complete description of what the business does:
Annual Receipts:
Prior Year Receipts:
Two Years Prior Receipts:
Prior Insurance Carrier:
Expiration Date:
-
Month
-
Day
Year
Date
Type Insurance Carried and Price:
Claims last five years - include cause and amount paid:
Comprehensive General Liability - Limits Desired (in thousands):
100/200
300/600
500/1000
1000/2000
Other
Professional Liability - Limits Desired (in thousands):
100/200
300/600
500/1000
1000/2000
Other
If Restaurant / Bar, Open Flame Cooking?
Yes
No
Describe fire prevention equipment in kitchen / wet or dry:
Liquor Sold?
Yes
No
If yes, annual sales:
Liquor License #:
Liquor Carry Out?
Yes
No
Food Delivery?
Yes
No
If yes, annual delivery sales:
# Drivers Per Day:
Their cars or company cars:
Property Coverage:
Own or Lease:
Building Construction Type:
# of Floors:
Other tenants in connected building:
Year Building Erected:
Sprinklers:
Yes
No
List other safety devices:
Central Fire Alarm:
Yes
No
Central Burglary Alarm:
Yes
No
If Own, Update Year For:
Heat:
Electric:
Plumbing:
Roof:
Type of Roof:
Year:
Value of Building:
Value of Business Personal Property:
Do you take in customer owned items (cars, items for repair, etc.)
Yes
No
If yes, average daily value:
Workers' Compensation:
Officers/Directors/Owners:
Name:
Job Duties:
Annual Salary:
Include/Exclude:
Date of Birth
Person 1:
Person 2:
Person 3:
Person 4:
Person 5:
Person 6:
# of Full Time Employees:
# of Part Time Employees:
Total Annual Payroll:
Please verify that you are human
*
Submit
Should be Empty: