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

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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 .