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. 
   --   Allow up to 1 week to receive a quotation, if application fully completed
   --   We will call for SS#(s) as most companies will not quote without

GENERAL INFORMATION

Named Insured:

 Contact:

Mailing Address:

 

City, State, Zip:

State:  Zip:  Phone:

County:

 Email:
 Physical Address of Property: Same   or List:

POLICY INFORMATION

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

HOME 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:        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

LIMITS OF INSURANCE

 DWELLING LIMIT:   DEDUCTIBLE:
  Replacement Cost? (Check if Desired):  Dwelling  Contents  
 CONTENTS LIMITS (FOR RENTERS ONLY):   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, what 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 (Multi Policy Credit will be Applied)
    MOTORCYCLE - We will contact you for information
    BOAT - We will contact you for information
    ATV, UTV - We will contact you for information

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

QUESTIONS / HELP

 Contact  Wanda Hodoba   or   Robb Gusic, AAI

Phone:

 (412) 271-8888 PA     (440) 639-9989 OH    8:30am-4:30pm

Fax:

 (412) 271-8898

Email:

 insurance@thompsongusic.com 

 

T.R.G.
Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  ALL RIGHTS RESERVED
Revised: April 06, 2016 .