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First Name 
Last Name
Phone Number
E-mail address 
 
Mailing Address:  
Street  
City 
State TX
Zip Code
Physical Address:  (Same as Mailing Address:  )
Street
City
State TX    
Zip Code

 

Business Name
FEIN or Social Security #
Type of Organization: Corporation    LLC   Partnership    Individual

 

Quote Information
How many years of experience?  
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Number of Employees: 
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Check any services that apply to your business:

In/Out Surgical Centers, Hospitals, Ambulatory Surgery Clinics, Emergency Room Services
Medical Laboratories
X-Ray/Radiology Centers/MRI Centers
Abortion Clinics
Blood Banks
Fertility Clinics
Organ / Tissue Donor Clinics
Home health care
Kidney Dialysis Centers
Weight Loss Centers
 
Payroll*      Gross Sales*   Total area of building or space leased* 
Liability Coverage
Liability limits requested:    Occurrence / Aggregate
Number of Additional Insureds 
Building and Contents
Do you own or lease? 
Building Coverage (if owned) 
Contents Coverage 
Deductible: 
Building Info:         
Year Built
Sq. Ft.
# of stories
Security
Construction Type: 
Other Information
Do you currently have coverage?  
If so, who is current carrier?  
Current annual premium:     
Expiration Date:

List any prior losses in the last five years:
Would you like quotes on:  Worker's Comp Commercial Auto Umbrella

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All Information submitted is used for underwriting purposes by the insurance company.  The companies use of credit information is in compliance with the Fair Credit Reporting Act.  Companies obtain this from consumer reporting agencies. It may include your driving record, claims history with other insurers, and credit report information. The information is kept by the consumer reporting agencies and disclosed by them to others as permitted by law.  Thompson-Hicks shall not be liable for any injury, loss, claim, or damage, nor any indirect, special, incidental or consequential damages of any kind, whether based in contract, tort, strict liability or otherwise, which arises out of the use of, or inability to use, this site or content found in this site, the unauthorized access to or alteration of your transmissions or data, even if Thompson-Hicks has been advised of the possibility of such damages. Some states do not allow the exclusion of liability for certain damages, so the foregoing exclusions or limitations may not apply to you.  No coverage is bound by submission of this form.  Privacy Policy 

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