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

Personal Auto
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 2 weeks to receive a quotation with a fully completed application

GENERAL INFORMATION

Named Insured:

 Contact:

Residence Address:

 Phone:

City, State, Zip:

State:  Zip:  Email:

County:

 Need By Date:

POLICY INFORMATION

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

DRIVER INFORMATION
- We will call for SS#(s) -

 NAME

DATE OF BIRTH

SEX

STATUS

DRIVER LICENSE  #
/ STATE LICENSED

 1. Male Female Married Single

#St

 2. Male Female Married Single

#St

 3. Male Female Married Single

#St

 4. Male Female Married Single

#St

ACCIDENTS  &  VIOLATIONS  -  Past 3 Years
Note:  Driver Records will be verified by State Reports.  Any undisclosed accidents or 
violations could result in an increase in premium or cancellation of coverage.

Driver #

Date of 
Accident / Violation

Description of Accident or Violation (Include MPH over speed limit for speeding violations)

VEHICLE INFORMATION

Year
( _ _ )

Make / Model / Type

V I N
(Vehicle Identification #)

Main
Driver
(List #)

Miles to
Work or
School

Pleasure
Use
Only

Compreh. Deductible

Collision
Deductible

 1.

 2.

 3.

 4.

LIMITS OF INSURANCE

 BODILY INJURY LIMITS

Each Person

 

Each Accident

 TORT OPTION (Choose One)

 

 Full Tort
 Limited Tort (limits right to sue unless serious injury, small discount applies)
 PROPERTY DAMAGE LIMIT

Each Accident

 UNINSURED MOTORIST LIMITS

Each Person

   Stacked Coverage  OR  Non-Stacked Coverage
 (Underinsured Limit will be same)    
 FIRST PARTY BENEFITS

 

Medical Payments:
Work Loss:
Funeral Expense:

Accidental Death:
 Towing Reimbursement Coverage:  List Vehicle #'s (above) to Request Towing Coverage:
 Rental Reimbursement Coverage:  List Vehicle #'s (above) to Request Rental Reimbursement Coverage:
 Lease Gap Coverage:  List Vehicle #'s (above)  which are Leased:

UNDERWRITING INFORMATION

   1.  Any drivers license been suspended? Y    N
   2.  Any other Losses / Claims not shown above? Y    N
   3.  Any driver have physical or mental impairment? Y    N
   4.  Do you currently have an auto policy in force? Y    N
   5.  Have you had continuous auto coverage for the last 6 months? Y    N
   6.  Have you had continuous auto coverage for the past year?       Y    N
   7.  Any coverage declined cancelled or non-renewed during the last 3 years? Y    N
   PLEASE EXPLAIN "Y" (Yes) answers above:

ADDITIONAL COVERAGES / COMMENTS / INFORMATION

 The above information is correct to the best of my knowledge.  Check:   Initials:
   WOULD ALSO LIKE A QUOTE FOR:
    HOMEOWNERS
- Please complete HOME OWNERS Quote Form on our website and "Submit"
   Companies can apply credits for Home Owners & Personal Auto Policies combined.

QUESTIONS / HELP

 Contact Pittsburgh Office

Phone:

 (412) 271-8888     8:30am-4:30pm   Mon-Fri

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 .