Homeowners Insurance Quote Form

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

Home Owners / Renters
Quote Form

  -   PA and OH only

   --   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. 

   --   If SS# is needed we will call for that.

GENERAL INFORMATION

Named Insured:

 Contact:

Mailing Address:

 

City, State, Zip:

State:  Zip:  Phone: This # isCell Biz Home

County:

 Email:
 Physical Address of Property: Same   or List:

POLICY INFORMATION

No Current Coverage: 
Current Company (not insurance agency):     Expiration Date:     Current Premium:

HOME / APARTMENT INFORMATION
NOTE: Home Owners & Tenants must complete the below information if any Property is to be covered.  

 Structure Type:   Dwelling....Apartment....Condo....Townhouse....Rowhouse....Co-Op
 Year Built (approx):        Construction Type: Frame.....Brick & Frame   Brick/Block        # Stories:      
 Type of Roof:Pitched...Flat     Livable Space (Areas Sq Ft):     # years living at this Residence:
 Swimming Pool?Y..N     If Yes;   Fenced In?Y..N     Diving Board?Y..N     Above..Below Ground
 Basement?Y..N       Unfinished    Partially Finished    Fully Finished
 UPDATES & RENOVATIONS ( Wiring, Heating, Roofing, Plumbing, Air Conditioning, Exterior Paint )
 
  Have all items above been updated or inspected within the past 10 years and are all in good condition?  N  

 PROPERTY PROTECTION
  # of Miles from Responding Fire Department:     # Feet from Fire Hydrant:    All Non-Smokers?Y..N
  Please check all that apply: Battery Smoke Detectors    Hardwired Smoke Detectors   100% Sprinklered
                                              Fire Alarm with central 24/7 monitoring   Burglar Alarm with central 24/7 monitoring  

LIMITS OF INSURANCE

 DWELLING LIMIT:   DEDUCTIBLE:
  Replacement Cost? (Check if Desired):  Dwelling  Contents  
 CONTENTS LIMITS (for Renters / Condo Units):   DEDUCTIBLE:
 PERSONAL  LIABILITY LIMIT:    
 MEDICAL PAYMENTS LIMIT: 
 UMBRELLA LIMIT: 
 
 OTHER COVERAGES & LIMITS (ie: Jewelry, Furs, Firearms, etc.)

UNDERWRITING 
(Explain "Yes" Answers Below in Comments Section)

 Any business conducted on premises? N  (Including day / child care)  Any other residence owned, occupied or rented? Y   N
 Any coverage declined, cancelled, or non-renewed during the last 3 years? N  Any foreclosure, repossession, or bankruptcy during the last 5 years? N
 Is there a trampoline on the premises? N  Is property located in a flood zone? N
 Are there any pets on the premises? Y N
  If Yes, type / breed?
 

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
    MOTORCYCLE - We will contact you for information
    BOAT - We will contact you for information
    ATV, UTV, Golf Cart - We will contact you for information

    Companies can apply credits for Home Owners & Personal Auto Policies combined.

QUESTIONS / HELP

 

Phone:

 (412) 271-8888 PA  8:30am-4:30pm

Fax:

 (877) 271-8898

Email:

 insurance@thompsongusic.com 

 

T.R.G.
Copyright © 2000 [Thompson-Gusic Insurance Group, Inc.].  ALL RIGHTS RESERVED
Revised: June 23, 2020 .