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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number:
Email Address:
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: