Kansas Preferred Insurance Group Package Quote Sheet
913-585-1981 34102 Commerce Dr Ste B De Soto, KS 66018 www.kpigroup.net
Client Name:
*
First Name
Last Name
Date of Birth
*
Driver's License Number
*
Spouse Name:
*
First Name
Last Name
Date of Birth
*
Driver's License Number
*
Address
*
Street Address
Street Address Line 2
City
Please Select
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State
Zip Code
Phone Number:
*
Email Address:
*
SMS Communication Consent:
Home Information:
Effective Date:
*
-
Month
-
Day
Year
Date
Current Carrier:
*
Year Built:
Square Footage:
Roof Type:
Please Select
Asphalt Shingles
Metal
Tile
Wood
Year Roof Replaced:
*
Number of Bathrooms: Full
Number of Bathrooms: Half
Garage Type:
Please Select
Attached
Built-In
Carpot
None
Garage Size Number of Cars:
Home Coverages
Dwelling Coverage:
Personal Liability Coverage:
Please Select
$ 300,000
$500,000
Guest Medical Coverage:
Please Select
$ 3000
$ 5000 - Recommended
All Peril Deductible:
Please Select
$ 1500
$ 2500
$ 1% of Dwelling Coverage
Wind & Hail Deductible:
Please Select
$ 1500
$ 2500
$ 5000
$ 1% Of Dwelling Coverage
Optional Coverages:
Equipment Breakdown Coverage
Water Backup Coverage
Identity Theft Coverage
Buried Lines Coverage
Do You Have a Swimming Pool?
Please Select
Yes
No
Do You Have a Burglar Alarm?
Please Select
Yes - Professionally Monitored
Yes - Not Professionally Monitored
No
Foundation Type:
Please Select
Basement
Crawlspace
Slab
Walkout Basement
Basement Finished Percentage:
Do You Have Any Dogs?
*
Please Select
Yes
No
Breed of Dog or Dogs:
Would You Like An Umbrella Quote?
Please Select
Yes
No
Umbrella Liability Limit:
Please Select
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Describe any losses or claims in the past 5 years.
Auto Information
Effective Date:
-
Month
-
Day
Year
Date
Current Insurance Company:
Policy Term Length:
Please Select
6 Months
12 Months
Billing Schedule:
Please Select
Monthly
Pay In Full
Auto Coverages
Bodily Injury Limit:
Please Select
$100,000/300,000
$300,000/300,000
$250,000/500,000
$500,000/500,000
Property Damage:
Please Select
100,000
250,000
300,000
500,000
Underinsured/Uninsured Motorist:
Please Select
$100,000/300,000
$300,000/300,000
$250,000/500,000
$500,000/500,000
Good Student Discount?
Please Select
Yes
No
Collision Deductible:
Please Select
$250
$500
$1000
N/A
Comprehensive Deductible:
Please Select
$250
$500
$1000
N/A
Vehicle 1: VIN Number
Vehicle 1: Coverage Requested
Full Coverage
Liability Only
Rental Car Coverage
Towing Coverage
Vehicle 2: VIN Number
Vehicle 2: Coverage Requested
Full Coverage
Liability Only
Rental Car Coverage
Towing Coverage
Vehicle 3: VIN Number
Vehicle 3: Coverage Requested
Full Coverage
Liability Only
Rental Car Coverage
Towing Coverage
Vehicle 4: VIN Number
Vehicle 4: Coverage Requested
Full Coverage
Liability Only
Rental Car Coverage
Towing Coverage
Vehicle 5: VIN Number
Vehicle 5: Coverage Requested
Full Coverage
Liability Only
Rental Car Coverage
Towing Coverage
Additional Drivers
Name:
First Name
Last Name
Date of Birth
Driver's License Number
Name:
First Name
Last Name
Date of Birth
Driver's License Number
Name:
First Name
Last Name
Date of Birth
Driver's License Number
Name:
First Name
Last Name
Date of Birth
Driver's License Number
Name:
First Name
Last Name
Date of Birth
Driver's License Number
Describe any losses or claims in the past 5 years.
Submit
Should be Empty: