Kannel Insurance Quote Form

Insurance Information Sheet

Home-Auto-Life
When should insurance start?

MonthDayYear
Date
Type of Coverage*

HomeRenter'sAutoHome and AutomobileBusinessOther
Applicant Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Preferred form of contact*
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Do you have current insurance coverage?*

YesNo
Who is your current insurance coverage with?
Insurance Company
Do you have a spouse or partner that should be listed?*

YesNo
SPOUSE OR PARTNER

First NameLast Name
Date of Birth*
Driver's License #*
Social Security Number*
How many drivers in household?

1234Other
YOUR Information

First NameLast Name
Date of Birth*
Driver's License #*
Social Security Number*
Is driver #2 below the same as your spouse or partner?*

YesNo
DRIVER TWO

First NameLast Name
Date of Birth*
Driver's License #
Social Security Number
DRIVER THREE

First NameLast Name
Date of Birth*
Driver's License #
Social Security Number
DRIVER FOUR

First NameLast Name
Date of Birth*
Driver's License #
Social Security Number
What is the Year, Make and Model of each vehicle to be insured?
If you have loans on your vehicles, what is the name and address of the bank?
If you have loans on your vehicles, How often do you make payments? (Yearly, Monthly, every 6 Months...etc.)
Are you interested in setting up automatic payments from your checking account?
Mailing Address (If PO Box - please also provide physical address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this the property you are insuring? (Note - if mailing address is a P.O. box, please provide physical address)*

YesNo
Property Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Appliances furnished by property owner (select all that apply)

StoveRefrigeratorWasherDryerOther
Do you have a computer or other electronic devices

YesNo
Do you have roomates?

YesNo
What is the home type?*

Single FamilyModularMobile HomeDwelling with more than one unit (state number of units in comment box below.
Do you own any animals?*

YesNo
What kind of animal?
Choose one
Please explain.
Please tell us what kind of animal(s) you own
What breed?
Breed of dog
Do you have any of the following? (check all that apply)

PoolTrampolineFenced YardHome Business
Do you have a fireplace or woodstove?*

YesNo
Where is your fireplace or woodstove located?
Select One
Please share a photo of the vehicle or residence you would like us to quote.
Anything else we need to know?
Providing information in this form neither offers or guarantees that coverage will be provided. All policies and premiums are subject to underwriting and rating guidelines. *
Required for submission
*IMPORTANT* Please scroll all the way to the bottom of the form and click the red "SUBMIT" button to complete the form.
Kannel Insurance

301 West Main St. Montpelier, Ohio 43543

Call or Text 419-485-4281

office@kannelinsurance.com
Please verify that you are human*
Business Information Sheet
Type of Business (Ex: contractor, plumber, salon...)*
Yearly Revenue*
Briefly share what kinds of services you offer *
Please email a copy of your current insurance declaration page to office@kannelinsurance.com.
Please share a photo of the property you would like us to quote.
Providing information in this form neither offers or guarantees that coverage will be provided. All policies and premiums are subject to underwriting and rating guidelines. *
Required for submission
Kannel Superior Agency Inc.

301 West Main St. Montpelier, Ohio 43543

Call or Text 419-485-4281

office@kannelinsurance.com
Should be Empty:

Insurance Information Sheet

Business Information Sheet