Business Owners Insurance Quote Form

   Back to QUOTE FORMS Page Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  
ALL RIGHTS RESERVED

Business Package
Quote Form
(Property & Liability)

    -   The "ENTER" or "RETURN" Key will submit the application.   Use the "TAB" Key and Mouse to navigate.
         If application is submitted by mistake, use the "BACK" Button on your browser to return to the application. 

    -   Allow up to 3 weeks to receive a quotation

GENERAL INFORMATION

Business Name:

 Phone:

Mailing Address:

 Contact:

City:

State:  Zip:  Fax:

Type of Entity:

Corp.   Partnership   Sole Prop.    Other:     Email:

Year Business Established:

     Years Experience in Field:  Website: www.

Federal ID #:

 Quote Need by Date:

 Business Description / Products Sold:

POLICY INFORMATION

 Current Carrier:     Expiration Date:     Current Premium:
 (Not Agency)  State "NONE" if no current coverage.

PREMISES # 1 INFORMATION
NOTE: Building Owners & Tenants must complete the below information if any Property is to be covered.  

 Location # 1:  Address, City, State, Zip:
 Occupancy (Ex: Office, Store, Shop):   Other Tenants Occupancies:
 Surrounding Area Best Described as:   City....Town....Rural    --&--   Residential....Commercial....Open         
 Bldg. Construction:   # Stories:   Approx. Square Feet You Occupy:   % of  Bldg You Occupy:
 Year Built:    Is Building Stand Alone or Connected to Buildings: Stand Alone...Connected        # of Apartments?
 Have the Electrical, Heating, Plumbing and Roof been updated or inspected within 10 Years and in good condition? Y..N


 PROPERTY PROTECTION

 Burglar Alarm:Y..N      Fire Alarm:Y..N      Are Alarms connected to Police/Fire or Monitored?Y..N  
 Fire Department within 5 miles?Y..N        Fire Hydrant within 1,000 Feet?Y..N        Is Building Sprinklered?Y..N  

PREMISES #1 LIMITS OF INSURANCE

 BUILDING LIMIT:  Replacement Cost...or...Actual Cash Value     Deductible     
 CONTENTS LIMIT:  Replacement Cost...or...Actual Cash Value     Deductible 
 Business Loss of Income:     Money & Securities (Robbery):    Employee Dishonesty:
 
 OTHER COVERAGES & LIMITS:
 (NOTE:  Only list special coverages / limits beyond the normal Business Owners Extensions.  Our quotes will include their own Extensions.

PREMISES #2 INFORMATION
If only one (1) premises, please scroll down to Liability Information & Limits Section

 Location # 2: Address, City, State, Zip:
 Occupancy (Ex: Office, Store, Shop):   Other Tenants Occupancies:
 Surrounding Area Best Described as:   City....Town....Rural    --&--   Residential....Commercial....Open         
 Bldg. Construction:   # Stories:   Approx. Square Feet You Occupy:   % of Bldg You Occupy:
 Year Built:     Is Building Stand Alone or Connected to Buildings: Stand Alone...Connected         # of Apartments?
 Have the Electrical, Heating, Plumbing and Roof been updated or inspected within 10 Years and in good condition? Y..N


 PROPERTY PROTECTION

 Burglar Alarm:Y..N      Fire Alarm:Y..N      Are Alarms connected to Police/Fire or Monitored?Y..N  
 Fire Department within 5 miles?Y..N       Fire Hydrant within 1,000 Feet?Y..N       Is Building Sprinklered?Y..N  

PREMISES #2,   LIMITS OF INSURANCE

 BUILDING LIMIT:  Replacement Cost...or...Actual Cash Value     Deductible     
 CONTENTS LIMIT:  Replacement Cost...or...Actual Cash Value     Deductible 
 Business Loss of Income:     Money & Securities (Robbery): 

 OTHER COVERAGES & LIMITS:
 (NOTE:  Only list special coverages / limits beyond the normal Business Owners Extensions.  Our quotes will include their own Extensions.

LIABILITY INFORMATION & LIMITS

 LIABILITY OCCURRENCE LIMIT:     $1,000,000     $500,000     $300,000     $100,000      Other:


 LIABILITY RATING

   Gross Annual Sales: 

LOSS INFORMATION  -  Past 3 Years

Date of Loss

Description of Loss  -  Enter "NONE" in Description Line below if no losses.

Amount Paid

ADDITIONAL COMMENTS / INFORMATION


 
The above information is correct to the best of my knowledge.  Check:   Initials:
  

   
  
WOULD ALSO LIKE A QUOTE FOR:

   AUTO - Quote Form is available on our site.  "COMMERCIAL AUTO"  
  WORKERS COMP - Quote Form is available on our site.  "WORKERS COMPENSATION
  UMBRELLA

 

QUESTIONS / HELP

 Contact Pittsburgh Office

Phone:

 (412) 271-8888   (9AM - 4:30PM E.S.T.)

Fax:

 (412) 271-8898

Email:

 insurance@thompsongusic.com   

 

T.R.G.
Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  ALL RIGHTS RESERVED
Revised: May 21, 2011 .