Commercial Insurance Quote Request
Tucker Insurance Agency, Inc.
Business Name:
*
Business Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address of Business
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business E-mail
*
example@example.com
Date Business Started:
*
Type ( sole proprietor. LLC, LLP, Corp):
*
FEIN:
*
Contact Name:
*
Contact Title:
*
Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Complete description of what the business does:
*
Annual Gross Income:
*
Prior Insurance Carrier:
*
If you don't have Prior Insurance Carrier, type "None"
Expiration Date:
-
Month
-
Day
Year
If you have Prior Insurance Carrier, please fill in this field
Type of Insurance Carried and Price:
If you have Prior Insurance Carrier, please fill in this field
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
Restaurant / Bar Business Only
If you are not a Restaurant or Bar Business click "No" or fill in "None"
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:
End of Restaurant / Bar Coverage Section
Property Coverage:
Own or Lease:
*
Build 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:
*
Rows
Heat
Electric
Plumbing
Roof
Year Updated:
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
If Own, Update Year For:
Rows
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 Employee:
Total Annual Payroll:
How did you hear about us?
*
Please Select
Website
Tucker Insurance Agent (Please specify name...)
Friend Referral (Please specify name...)
Other (Please specify...)
Specify the name for the previous question....
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Submit
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