Kannel Insurance Quote Form

Insurance Information Sheet

Home-Auto-Life-Health
When should insurance start?

Month Day Year
Date
Type of Coverage *

Home Renter's Auto Home and Automobile Business Life and Health
Applicant Name *

First Name Last Name
Date of Birth *
Phone Number *

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

Yes No
Who is your current insurance coverage with?
Insurance Company
Are you or have you ever been a smoker? *

Yes No
Do you have a spouse or partner that should be listed? *

Yes No
SPOUSE OR PARTNER

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

1 2 3 4
Your Information

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

Yes No
DRIVER TWO

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

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

First Name Last 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

City State / Province

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

Yes No
Property Address

Street Address

Street Address Line 2

City State / Province

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

Stove Refrigerator Washer Dryer Other
Do you have a computer or other electronic devices

Yes No
Do you have roomates?

Yes No
What is the home type? *

Single Family Modular Mobile Home Dwelling with more than one unit (state number of units in comment box below.
Do you own any animals? *

Yes No
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)

Pool Trampoline Fenced Yard Home Business
Do you have a fireplace or woodstove? *

Yes No
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
Kannel Superior Agency Inc.

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 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
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Insurance Information Sheet

Business Information Sheet