AFFORD-A-SURANCE-**QUOTE**

Applicant Information

First Name *

Last Name *

Middle Inital

Full Physical Address (Where the vehicle(s) is kept) *

Zip Code *

Number of vehicles to be quoted *

Personal Information

Date of Birth *

Male / Female *

Marital Status *

License Status *

Are you required by Driver Control to File an SR22? *

If you selected Yes, ANOTHER STATE not Kansas; In which State is the SR22 required?

List all Violations for yourself in the last three years *

List all Accidents and Comprehensive Claims for yourself in the last 5 years *

Have you completed a Kansas Approved accident prevention course in the last three years? *

Have you maintained continuous liability insurance with no late payments for the last six months? *

If you answered yes to the question when does/did your current policy expire?

What is the name of your current Insurance Company?

What are your current limits of liability? We offer a discount for having current insurance for the last six months. This information helps determin the amount of the discount.

Do you own or rent your home? * We offer a discount on auto insurance for Home owners (proof of homeownership required)

Would you like a Homeowner quote? *

Would you like a quote for renter's Insurance? *

Spouse Information

Spouse's Full Name Here *

List all violations your spouse has for the last three years *

List all Accidents for the last 5 years your spouse has obtained (regardless of fault) if they were not at fault accidents please indicate *

Spouse Date of Birth *

Spouse License Status *

Number of Additional Drivers * List all other drivers and house hold members age 14 and older regardless if they drive your vehicle.

Vehicle # 1

Vehicle Year *

Make *

Model *

Vehicle Identification Number (VIN) *

Limits Of Liability *

Comprehensive Deductible * The amount you pay out of pocket in the event of a covered loss

Collision Deductible * The amount you pay out of pocket in the event of a covered loss

Towing * only available on physical damage policies

Rental * Only available on Physical Damage Policies

Emergency Roadside * Available on Liability and Physical Damage Policies

Is there a Lien Holder for this Vehicle? *

Does the vehicle have a clean Title? *

Are you the sole owner of this vehicle? (all owners must be listed unless they have their own Insurance Policy) Please List all owners with their name, date of birth, license status, tickets/accidents below. If they have their own insurance please indicate. *

Discounts Available

Please select money saving discounts you would like to add (subject to company availability) PRESS CTRL TO SELECT MULTIPLE DISCOUNTS *

Vehicle #2

Vehicle Year *

Make *

Model *

Vehicle Identification Number (VIN) *

Limits Of Liability *

Comprehensive Deductible * The amount you pay out of pocket in the event of a covered loss

Collision Deductible * The amount you pay out of pocket in the event of a covered loss

Towing * only available on physical damage policies

Rental * Only available on Physical Damage Policies

Emergency Roadside * Available on Liability and Physical Damage Policies

Is there a Lien Holder for this Vehicle? *

Does the vehicle have a clean Title? *

Are you the sole owner of this vehicle? (all owners must be listed unless they have their own Insurance Policy) Please List all owners with their name, date of birth, license status, tickets/accidents below. If they have their own insurance please indicate. *

Vehicle #3

Vehicle Year *

Make *

Model *

Vehicle Identification Number (VIN) *

Limits Of Liability *

Comprehensive Deductible * The amount you pay out of pocket in the event of a covered loss

Collision Deductible * The amount you pay out of pocket in the event of a covered loss

Towing * only available on physical damage policies

Rental * Only available on Physical Damage Policies

Emergency Roadside * Available on Liability and Physical Damage Policies

Is there a Lien Holder for this Vehicle? *

Does the vehicle have a clean Title? *

Are you the sole owner of this vehicle? (all owners must be listed unless they have their own Insurance Policy) Please List all owners with their name, date of birth, license status, tickets/accidents below. If they have their own insurance please indicate. *

Additional Drivers

First name *

First Name *

Last Name *

Date Of Birth *

License Status *

Male / female *

Tickets last three years Accidents and Comprehensive claims last five years *

Additional Drivers

First name *

First Name *

Last Name *

Date Of Birth *

License Status *

Male / female *

Tickets last three years Accidents and Comprehensive claims last five years *

Additional Drivers

First name *

First Name *

Last Name *

Date Of Birth *

License Status *

Male / female *

Tickets last three years Accidents and Comprehensive claims last five years *

Contact Information

Email *

Phone number *

Preferred method of contact * PhoneUS Mail

Renter Quote/Tenant

Rental Property Address *

Zip Code *

Property Type *

How many units between firewalls? *

Fireplace? *

How much coverage do you need for your contents (all of YOUR personal belongings inside the home)? *

Limit of Liability needed *

Choose your Deductible (the amount you pay out of pocket in the event of a covered loss) *

Choose all that apply to your home (press ctrl to select more than one option) *

Construction Type *

Homeowner Quote Request

Year Built *

Style of Home *

Basement *

Percentage of Basement Finished *

Do you have a crawlspace or Slab? *

Percentage of Crawlspace under the home. *

Percentage of Slab under the home *

Garage *

Airconditioning *

How old is the Airconditioning *

Heating *

When was the Central Gas Heating Unit Replaced *

Year Home Purchased *

Square Footage *

Number of Bedrooms *

Number of Bathrooms *

Quality of build materials (inside) ex cabinets, carpet, tile etc. *

Fireplace *

When was the wiring updated *

Roof Type (ex Asphault Shingles) *

When was Roof Built or replaced? *

Do you have a sliding glass door? *

Are there any bay windows in the home? *

Is there a deck? *

size of deck *

Enclosed/screened Porch *

size of enclosed/screened porch *

Do you need coverage for waterback up of sewers and sump pumps? *

Limit of Liability *

Deductible *

Wind Hail Storm percentage deductible *

Auto Quote Request

Spouse Information

Vehicle # 1

Vehicle #2

Vehicle #3

Additional Drivers

Additional Drivers

Additional Drivers

Contact Information

Renter Quote/Tenant

Homeowner Quote Request