Home Owners Quote Form

Homeowners Insurance Quote Form

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? Y 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? Y 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? Y N	Any foreclosure, repossession, or bankruptcy during the last 5 years? Y N
Is there a trampoline on the premises? Y N	Is property located in a flood zone? Y 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