Property Insurance Quote Form

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Copyright 2000 [Thompson-Gusic Insurance Group,Inc.].  ALL RIGHTS RESERVED

Property Quote Form

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  -   Allow up to 3 weeks to receive a quotation
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EXPLANATION POP UPfor additional information.

GENERAL INFORMATION

Business Legal Name:

Phone:

Mailing Address:

Contact:

City:

State:  Zip: Email:

POLICY INFORMATION

 Check if No Current Insurance Coverage, or Complete Below:
 Current Carrier:     Expiration Date:     Current Premium:
  (Not Agency)  State "NONE" if no current coverage.

INFORMATION & LIMITS OF INSURANCE
NOTE: Building Owners & Tenants must complete the below information if any Property is to be covered.  

 LOCATION #1
 Physical Address, City, State, Zip:
 Occupancy (Ex: Office, Store, Shop, Storage):   Other Tenants Occupancies:
 Surrounding Area Best Described as:   City....Town....Rural    --&--   Residential....Commercial....Open         
 ConstructionEXPLANATION POP UP:   # Stories:   Square Feet Occupied by You:   Total Sq. Feet Bldg:
 Year Built:    Is Bldg Stand Alone or Connected to Bldg's: Stand Alone..Connected   # of Apartments?
 Updates to Bldg EXPLANATION POP UP:  Electrical:  Plumbing:   Heating/AC:   Roof:   or All Within 10 Years?Y..N
 Is Property Located in a Flood Zone?Y..N      # of Feet from River?   

 PROPERTY PROTECTION

 Is there a Central Station EXPLANATION POP UP  Burglar Alarm?Y..N      Fire Alarm?Y..
 # of Miles to Fire Department?   # Feet to Fire Hydrant?or None (check)   Is Building Sprinklered?Y  If Yes, What %?

 LIMITS OF INSURANCE

 Building Limit EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 Contents Limt EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 Choose your Property Deductible EXPLANATION POP UP: This Deductible will apply to all Locations & Buildings
 EQUIPMENT FLOATER EXPLANATION POP UP Equipment Floater limits only need to be entered once, as coverage is not limited to any location.
  Miscellaneous Tools & Equipment, Total Value EXPLANATION POP UP
:     Scheduled Equipment, Total Value EXPLANATION POP UP:
 
Choose your Tools / Equipment Deductible EXPLANATION POP UP: This Deductible will only apply to this coverage.
  Briefly describe WHERE the equipment is stored overnight (ie shed, warehouse, etc) and TYPE of security (ie locks, fenced, etc)
 

  What is the maximum value of all equipment that is not stored inside a structure overnight? or N/A (all inside)

  Does the structure you store your equipment in most of the time (and overnight) have a central station

     EXPLANATION POP UP Burglar Alarm?Y..N      Fire Alarm?Y..N
  Other Notable Coverages You May Have For Any of Your Locations:  (Please list)
 If you have no more locations or buildings CLICK HERE to Skip to End of Form
 LOCATION OR BUILDING #2
 ADDRESS SAME AS ABOVE,   OR Address, City, State, Zip:
 Occupancy (Ex: Office, Store, Shop, Storage):   Other Tenants Occupancies:
 Surrounding Area Best Described as:   City....Town....Rural    --&--   Residential....Commercial....Open         
 ConstructionEXPLANATION POP UP:   # Stories:   Square Feet Occupied by You:   Total Sq. Feet Bldg:
 Year Built:    Is Bldg Stand Alone or Connected to Bldg's: Stand Alone..Connected   # of Apartments?
 Updates to Bldg EXPLANATION POP UP:  Electrical:  Plumbing:   Heating/AC:   Roof:   or All Within 10 Years?Y..N
 Is Property Located in a Flood Zone?Y..N      # of Feet from River?   

 PROPERTY PROTECTION

 Is there a Central Station EXPLANATION POP UP  Burglar Alarm?Y..N      Fire Alarm?Y..
 # of Miles to Fire Department?   # Feet to Fire Hydrant? or None (check)    Is Building Sprinklered?Y  If Yes, What %?

 LIMITS OF INSURANCE

 Building Limit EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 Contents Limt EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 If you have no more locations or buildings CLICK HERE to Skip to End of Form
 LOCATION OR BUILDING #3
 ADDRESS SAME AS ABOVE,   OR Address, City, State, Zip:
 Occupancy (Ex: Office, Store, Shop, Storage):   Other Tenants Occupancies:
 Surrounding Area Best Described as:   City....Town....Rural    --&--   Residential....Commercial....Open         
 ConstructionEXPLANATION POP UP:   # Stories:   Square Feet Occupied by You:   Total Sq. Feet Bldg:
 Year Built:    Is Bldg Stand Alone or Connected to Bldg's: Stand Alone..Connected   # of Apartments?
 Updates to Bldg EXPLANATION POP UP:  Electrical:  Plumbing:   Heating/AC:   Roof:   or All Within 10 Years?Y..N
 Is Property Located in a Flood Zone?Y..N      # of Feet from River?   

 PROPERTY PROTECTION

 Is there a Central Station EXPLANATION POP UP  Burglar Alarm?Y..N      Fire Alarm?Y..
 # of Miles to Fire Department?   # Feet to Fire Hydrant? or None (check)   Is Building Sprinklered?Y  If Yes, What %?

 LIMITS OF INSURANCE

 Building Limit EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 Contents Limt EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 If you have no more locations or buildings CLICK HERE to Skip to End of Form
 LOCATION OR BUILDING #4
 ADDRESS SAME AS ABOVE,   OR Address, City, State, Zip:
 Occupancy (Ex: Office, Store, Shop, Storage):   Other Tenants Occupancies:
 Surrounding Area Best Described as:   City....Town....Rural    --&--   Residential....Commercial....Open         
 ConstructionEXPLANATION POP UP:   # Stories:   Square Feet Occupied by You:   Total Sq. Feet Bldg:
 Year Built:    Is Bldg Stand Alone or Connected to Bldg's: Stand Alone..Connected   # of Apartments?
 Updates to Bldg EXPLANATION POP UP:  Electrical:  Plumbing:   Heating/AC:   Roof:   or All Within 10 Years?Y..N
 Is Property Located in a Flood Zone?Y..N      # of Feet from River?   

 PROPERTY PROTECTION

 Is there a Central Station EXPLANATION POP UP  Burglar Alarm?Y..N      Fire Alarm?Y..
 # of Miles to Fire Department?   # Feet to Fire Hydrant? or None (check)   Is Building Sprinklered?Y  If Yes, What %?

 LIMITS OF INSURANCE

 Building Limit EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 Contents Limt EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 If you have no more locations or buildings CLICK HERE to Skip to End of Form
 LOCATION OR BUILDING #5
 ADDRESS SAME AS ABOVE,   OR Address, City, State, Zip:
 Occupancy (Ex: Office, Store, Shop, Storage):   Other Tenants Occupancies:
 Surrounding Area Best Described as:   City....Town....Rural    --&--   Residential....Commercial....Open         
 ConstructionEXPLANATION POP UP:   # Stories:   Square Feet Occupied by You:   Total Sq. Feet Bldg:
 Year Built:    Is Bldg Stand Alone or Connected to Bldg's: Stand Alone..Connected   # of Apartments?
 Updates to Bldg EXPLANATION POP UP:  Electrical:  Plumbing:   Heating/AC:   Roof:   or All Within 10 Years?Y..N
 Is Property Located in a Flood Zone?Y..N      # of Feet from River?   

 PROPERTY PROTECTION

 Is there a Central Station EXPLANATION POP UP  Burglar Alarm?Y..N      Fire Alarm?Y..
 # of Miles to Fire Department?   # Feet to Fire Hydrant? or None (check)   Is Building Sprinklered?Y  If Yes, What %?

 LIMITS OF INSURANCE

 Building Limit EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 Contents Limt EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 If you have no more locations or buildings CLICK HERE to Skip to End of Form
 LOCATION OR BUILDING #6
 ADDRESS SAME AS ABOVE,   OR Address, City, State, Zip:
 Occupancy (Ex: Office, Store, Shop, Storage):   Other Tenants Occupancies:
 Surrounding Area Best Described as:   City....Town....Rural    --&--   Residential....Commercial....Open         
 ConstructionEXPLANATION POP UP:   # Stories:   Square Feet Occupied by You:   Total Sq. Feet Bldg:
 Year Built:    Is Bldg Stand Alone or Connected to Bldg's: Stand Alone..Connected   # of Apartments?
 Updates to Bldg EXPLANATION POP UP:  Electrical:  Plumbing:   Heating/AC:   Roof:   or All Within 10 Years?Y..N
 Is Property Located in a Flood Zone?Y..N      # of Feet from River?   

 PROPERTY PROTECTION

 Is there a Central Station EXPLANATION POP UP  Burglar Alarm?Y..N      Fire Alarm?Y..
 # of Miles to Fire Department?   # Feet to Fire Hydrant? or None (check)    Is Building Sprinklered?Y  If Yes, What %?

 LIMITS OF INSURANCE

 Building Limit EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 Contents Limt EXPLANATION POP UP: Coverage is written as Replacement Cost EXPLANATION POP UP  If you want Actual Cash Value check here.
 *
 Have all Locations & Buildings been Entered?
Yes No  If NO, we will contact you for the remaining information.

LOSS INFORMATION  -  Past 3 Years

 

CHECK HERE IF NO CLAIMS 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:
   If Enter Button was pressed (Enter Button Submits the Form), use "Tab" key or Mouse to navigate. Submit Button is at bottom.

QUESTIONS / HELP

 Contact Office

Phone:

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

Fax:

 (877) 271-8898

Email:

 insurance@thompsongusic.com   

 

T.R.G.
Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  ALL RIGHTS RESERVED
Revised: October 12, 2017 .