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   WHOLESALERS PROGRAM Description Page		 Copyright © 2000 [Thompson-Gusic Insurance Group, Inc.].  
ALL RIGHTS RESERVED

Wholesalers / Distributors
Quote Form

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       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:

 Contact:

Mailing Address:

 Phone:

City:

 State:  Zip:  Fax:

Type of Entity:

 Corp.   Partnership   Sole Prop.    Other:     Email:

Federal ID #

 (aka FEIN)  Website www.

Year Business Established:

    Years Experience: Quote Need by Date:

List Owners Names: 

  
 Business Description / Products Sold:

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

 IF NEW IN BUSINESS, please give brief explanation of past experience in your field of business, and any past business experience:

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


 OFFICE / FACILITY INFORMATION  (If separate Distribution Facilities, list these below in Storage Facilities section)

 Loc # 1:  Address, City, State, Zip:
 BUILDING INFO:   Type:..Frame...Brick / Frame...Brick / Block          Condition:..Excellent...Good...Fair 
  Year Built:    # Stories:   Tot. Sq. Ft (Include All Floors):  Total Sq. Ft. You Occupy:
  Building has:..Burglar Alarm...Fire Alarm    Burg Alarm is Monitored? Y  N   Fired Alarm is Monitored? Y  N
 BUILDING LIMIT:   OFFICE CONTENTS (Only) LIMIT:    STOCK / PRODUCT LIMIT:
 POLICY DEDUCTIBLE:...$250......$500......$1,000......$2,500......Other Desired:
 

 Loc # 2:  Address, City, State, Zip:
 BUILDING INFO:   Type:..Frame...Brick / Frame...Brick / Block          Condition:..Excellent...Good...Fair 
  Year Built:    # Stories:   Tot. Sq. Ft:         Building has:..Burglar Alarm...Fire Alarm...Sprinklers
 BUILDING LIMIT:   OFFICE CONTENTS (Only) LIMIT:    STOCK / PRODUCT LIMIT:
 


 OTHER STORAGE / DISTRIBUTION FACILITIES INFORMATION

 Storage # 1:  Address, City, State, Zip:
 Bldg. Construction:    Is Building Alarmed?Y..N     Sprinklered?Y..N      24 Hour Watchmen?Y..N
 BUILDING LIMIT (If Owned):        MAXIMUM STOCK VALUE / LIMIT (At Any One Time):
 

 Storage # 2:  Address, City, State, Zip:
 Bldg. Construction:    Is Building Alarmed?Y..N     Sprinklered?Y..N      24 Hour Watchmen?Y..N
 BUILDING LIMIT (If Owned):        MAXIMUM STOCK VALUE / LIMIT (At Any One Time):
 

 Storage # 3:  Address, City, State, Zip:
 Bldg. Construction:    Is Building Alarmed?Y..N     Sprinklered?Y..N      24 Hour Watchmen?Y..N
 BUILDING LIMIT (If Owned):        MAXIMUM STOCK VALUE / LIMIT (At Any One Time):
 

 Storage # 4:  Address, City, State, Zip:
 Bldg. Construction:    Is Building Alarmed?Y..N     Sprinklered?Y..N      24 Hour Watchmen?Y..N
 BUILDING LIMIT (If Owned):        MAXIMUM STOCK VALUE / LIMIT (At Any One Time):
 

 Storage # 5:  Address, City, State, Zip:
 Bldg. Construction:    Is Building Alarmed?Y..N     Sprinklered?Y..N      24 Hour Watchmen?Y..N
 BUILDING LIMIT (If Owned):        MAXIMUM STOCK VALUE / LIMIT (At Any One Time):
 

 Storage # 6:  Address, City, State, Zip:
 Bldg. Construction:    Is Building Alarmed?Y..N     Sprinklered?Y..N      24 Hour Watchmen?Y..N
 BUILDING LIMIT (If Owned):        MAXIMUM STOCK VALUE / LIMIT (At Any One Time):
 

PROPERTY IN TRANSIT
 Do you want a quote for your "Owned" goods while in Transit?  Yes   No (Skip Section) 
 Limit in Transit Per Vehicle by Common Carrier:  Total Annual Shipped Values Per Common Carrier:
 Limit in Transit Per Vehicle for Owned Vehicles:  Total Annual Shipped Values on Your Owned Vehs:

LIABILITY INFORMATION & LIMITS
 LIABILITY OCCURRENCE LIMIT:     $1,000,000     $500,000     $300,000     $100,000    Other:


 LIABILITY RATING
   TYPE(S) OF PRODUCTS SOLD:
  PRODUCTS COUNTRY(S) OF ORIGIN:
   GROSS ANNUAL SALES: 

UMBRELLA POLICY LIMITS (If Needed)
 LIMIT OF LIABILITY:  $1,000,000    $2,000,000    Other:    

UNDERWRITING INFORMATION
 Are Foreign Products Sold or Distibuted?  Y   N  Are Products of Others Sold Under Your Label?           Y   N
 Are Products Sold Under Label of Others? Y   N  Are Products of Others Re-Packaged Under Your Label? Y   N
 Any Foreign Sales?  Y   N     Percent?  

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 - Please complete COMMERCIAL AUTO Quote Form on our website and "Submit"
       
   WORKERS COMPENSATION - Please complete WORKERS COMPENSATION Quote Form  

 

QUESTIONS / HELP

  Contact Pittsburgh Office

Phone:

  (412) 271-8888   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: April 06, 2016 .