Vacant / Rented Dwelling Request
Tucker Insurance Agency, Inc.
Your Name:
First Name
Last Name
Contact Name:
First Name
Last Name
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
-
Area Code
Phone Number
Membership (Alumni/AARP):
County:
Date of Birth:
SSN:
Responding Fire Dept:
Miles to Fire Dept:
Feet to Hydrant:
Coverage A Amount (PP Renters):
Number of Rooms (Renters):
Updates:
Roof:
Wiring:
Heating:
Plumbing:
Year Updated:
Dead Bolt:
Yes
No
Smoke Alarm:
Yes
No
Fire Extinguisher:
Yes
No
Central Burglary or Fire Alarm:
Yes
No
Back Up Sewer/Water/Drain:
2,000
5,000
10,000
25,000
50,000
Losses (3-5 Years) including Amount Paid & Reason:
Earthquake:
Yes
No
Deductible:
Secured (How)
# of Units
Utilities On:
Yes
No
Liability Limits:
100,000
300,000
500,000
Med Pay:
1,000
2,500
5,000
10,000
Deductible
100/1000 wind
250/1000 wind
1000
2500
5000
Vacant Date:
Reason Vacant:
Renovations Amount:
Type of Renovations:
Mortgage Company:
Loan Number:
Address:
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