Kannel Insurance Quote Form

When should insurance start?

Date

Type of Coverage

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?

Who is your current insurance coverage with?

Insurance Company

Do you have a spouse or partner that should be listed?

SPOUSE OR PARTNER

First NameLast Name

Date of Birth

Driver's License #

Social Security Number

How many drivers in household?

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?

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)

Property Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Appliances furnished by property owner (select all that apply)

Do you have a computer or other electronic devices

Do you have roomates?

What is the home type?

Do you own any animals?

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)

Do you have a fireplace or woodstove?

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

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

Insurance Information Sheet

Business Information Sheet