AFFORD-A-SURANCE-**QUOTE**

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ABOUT YOU
YOUR VEHICLE

FIRST NAME *

LAST NAME *

ADDRESS *

ZIP CODE *

ANY OTHER HOUSE HOLD MEMBERS 14 OR OLDER? * YESNO

OTHER HOUSE HOLD MEMBERS 14 OR OLDER MUST BE LISTED WHETHER OR NOT THEY DRIVE YOUR VEHICLE, IF THEY ARE UNLICENSED THE CAN BE LISTED BUT NOT RATED.

Marital Status * MarriedSingleMarried but not living together and spouse is not on my title

If you are married your spouse must be listed unless you are seperated and they are not listed on the title or registration to any vehicle being quoted.

Your Date of birth *

Your License status * ValidSuspended but can reinstate within 30 days Suspended- will not reinstate for 31 days or moreExpired and will renew within 7 daysExpired will not renew for 8 days or moreRevokedNever Licensed

Determining your license status will help us decide which Insurance company to quote you with.

Are you required by Kansas Driver Control to file an SR-22? * YesNo

To contact Driver Control call 1-785-296-3671

List all Tickets Accidents in the last 3 years, this includes No proof of insurance tickets and Driving on suspended License and Not at fault accidents! *

Be accurate, we need to know about all violations in the last 3 years regardless if they have been paid or not.

If you are married list your spouses Full name, DOB, License status, and any tickets accidents and any violations received in the last 3 years; and if an sr-22 is required.

If there are other drivers or house hold members 14 or older, list their full names, DOB, License status, and any violations and accidents in the last 3 years.

IF OTHER HOUSE HOLD MEMBERS 14 OR OLDER, DO THEY HAVE THEIR OWN INSURANCE? WILL THEY BE DRIVING YOUR VEHICLE? *


YOUR VEHICLE

YEAR *

MAKE *

CHEVY, DODGE, PONTIAC, ETC.

MODEL *

SUNFIRE, AVEO, YUKON, ENTER WHAT KIND OF VEHICLE, ETC

VIN (VEHICLE IDENTIFICATION NUMBER) *

THE VIN IS FOUND ON THE WINDOW (DASH BOARD) DRIVER'S SIDE DOOR, OR ON A TITLE OR REGISTRATION.

DESIRED LIMITS OF LIABILITY * 25,000/50,000/10,000 (the minimum kansas requires)25,000/50,000/15,00025,000/50,000/25,00050,000/100,000/50,000100,000/300,000/100,000I need liability limits in excess of 200,000

LIABILITY COVERAGE IS REQUIRED IN THE STATE OF KANSAS!

If full coverage is desired what deductibles do you want? * 100/100 Comprehensive and Collision250/250 Comprehensive and Collision500/500 Comprehensive and Collision1000/1000 Comprehensive and Collision2000/2000 Comprehensive and CollisionI do not want Full Coverage; I only need Liability

In the event of a loss, what is the maximum amount you could pay out of pocket?

Do you need coverage for Towing? * YesNo

In the event your vehicle becomes disabled, this coverage would pay for your vehicle to be towed.

Do you need Rental Reimbursement Coverage? * YesNo

In the event of an accident this coverage would pay for a rental vehicle if yours is not driveable

Do you need Emergency Roadside Service? * YesNo

In the event a covered vehicle breaks down ERS would deliver gas, fix a tire, get you back in your car if you get locked out, etc.

Any other vehicles to be quoted? If yes list Year Make Model and Vin if available; and desired coverages! *

List other vehicles to be quoted, and desired coverages, liability limits and if you want comp and coll type in the amount of deductibles you need; etc. be accurate!

DISCOUNTS

DO YOU OWN OR RENT YOUR HOME? * RENTOWN

DO YOU HAVE 6 MONTHS PROOF OF PRIOR INSURANCE WITH NO LAPSES, AND NOT EXPIRING MORE THAN 25 DAYS AGO? * YES, AND I NEVER PAID LATE, MY POLICY IS STILL ACTIVENONEVER HAD INSURANCEYES BUT PAID LATE OR IT EXPIRED MORE THAN 25 DAYS AGO

IF YOU HAVE 6 MONTHS OF PRIOR INSURANCE, WHICH INSURANCE COMPANY AND WHAT IS THE CURRENT EXPIRATION DATE?

HAVE YOU COMPLETED AN ACCIDENT PREVENTION COURSE OR A DEFENSIVE DRIVER COURSE? * YESNOYES BUT IT WAS COURT ORDERED

WE MAY BE ABLE TO OFFER A DISCOUNT BUT THE COURSE COULD NOT BE COURT ORDERED AND YOU MAY HAVE NO MORE THAN 1 ACCIDENT ON YOUR DRIVING RECORD.

OTHER IMPORTANT INFORMATION

PLEASE LIST OTHER INFORMATION YOU BELIEVE MAY BE NEEDED TO GIVE A QUOTE. *

TELEPHONE NUMBER *

EMAIL *

HOW WOULD YOU LIKE TO BE CONTACTED REGARDING YOUR QUOTE? * EMAILPHONEUS MAILNO PREFERENCE

PLEASE SELECT YOUR PREFERRED METHOD OF CONTACT; THE AGENT WILL CONTACT YOU THROUGH YOUR PREFERRED METHOD.

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AFFORD-A-SURANCE-**QUOTE REQUEST**

AFFORD-A-SURANCE-QUOTE REQUEST