Contractors Insurance Quote Form

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

Contractors Package
Quote Form

 - 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

GENERAL INFORMATION

Business Name:

 Phone:

Mailing Address:

 Contact:

City:

State:  Zip:  Fax:

Type of Entity:

C Corp  S Corp Partnership Individual LLC  Other:     Email:

Year Business Established:

   Years Experience in Field:  Quote Need by Date:

Federal ID # (FEIN):

 
 Business Description:
 If a new business list
experience:

POLICY INFORMATION

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

PREMISES # 1 INFORMATION
NOTE: Building Owners & Tenants must complete the below information if any Property is to be covered.  

 Location # 1:  Address, City, State, Zip:
 Occupancy (Ex: Office, Store, Shop):   Other Tenants Occupancies:
 Bldg. Construction:   # Stories:   Approx. Square Feet You Occupy:   % of Bldg You Occupy:
 Year Built:  Is Building Stand Alone or Connected to Buildings? Stand Alone..Connected    # of Apartments?
 Updates to Bldg (Year):  Electrical  Plumbing  Heating/AC   Roof   or All Within 10 Years?Y..N
 PROPERTY PROTECTION
 Burglar Alarm:
Y..N      Fire Alarm:Y..N      Are Alarms connected to Police/Fire or Monitored?Y..N  
 Fire Department within 5 miles?Y..N      Fire Hydrant w/in 1,000 Feet?Y..N      Is Building Sprinklered?Y..

PREMISES #1 LIMITS OF INSURANCE

 BUILDING LIMIT:  Replacement Cost...or...Actual Cash Value     Deductible     
 CONTENTS LIMIT:  Replacement Cost...or...Actual Cash Value     Deductible 
 CONTRACTORS TOOL/EQUIP. FLOATER:  Misc. Total Value:                  Scheduled Total Value:
                                                                         (Total All Items less than $2,000 each)     (Total All Items greater than $2,000 each)
  Other Coverages & Limits:
  

PREMISES #2 INFORMATION
If only one (1) premises, please scroll down to Liability Information & Limits Section

 Location # 2: Address, City, State, Zip:
 Occupancy (Ex: Office, Store, Shop):   Other Tenants Occupancies:
 Bldg. Construction:   # Stories:    Approx. Square Feet You Occupy:   % of Bldg You Occupy:
 Year Built:   Is Building Stand Alone or Connected to Buildings:Stand Alone..Connected    # of Apartments?
 Updates to Bldg (Year):  Electrical   Plumbing   Heating/AC    Roof   or All Within 10 Years?Y..N
 PROPERTY PROTECTION
 Burglar Alarm:
Y..N      Fire Alarm:Y..N      Are Alarms connected to Police/Fire or Monitored?Y..N  
 Fire Department within 5 miles?Y..N      Fire Hydrant w/in 1,000 Feet?Y..N     Is Building Sprinklered?Y..

PREMISES #2,   LIMITS OF INSURANCE

 BUILDING LIMIT:  Replacement Cost...or...Actual Cash Value     Deductible     
 CONTENTS LIMIT:  Replacement Cost...or...Actual Cash Value     Deductible 

 Other Coverages & Limits:
 

LIABILITY INFORMATION & LIMITS

 LIABILITY OCCURRENCE LIMIT:
 UMBRELLA LIMIT OPTION (Only Applicable if $1,000,000 is carried on above Limit):
 
 # of Owners / Officers:     Total # of Laborer Employees: (Do not include office / clerical employees)
 % of Work Subcontracted:  Type of Work Subcontracted:
 Do you obtain Certificates of Insurance from subcontractors:Y..N
 List Class of Operations (ie: Carpentry, Drywall, Heating/AC, Painting, Electrical, etc...)

# of Employees

 Payroll (Annual)
  

  

  

  

  

LOSS INFORMATION  -  Past 5 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 - Quote Form is available on our site.  "COMMERCIAL AUTO Quote Form"
   WORKERS COMP - Quote Form is available on our site.  "WORKERS COMPENSATION"     
   UMBRELLA  
 

QUESTIONS / HELP

 Contact Pittsburgh Office

Phone:

 (412) 271-8888   (9AM - 4:30PM EST)

Fax:

 (412) 271-8898

Email:

 insurance@thompsongusic.com   



T.R.G.
Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  ALL RIGHTS RESERVED
Revised: July 14, 2016 .