Kansas Preferred Insurance Group Renter's 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
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Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Utah
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West Virginia
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State
Zip Code
Phone Number:
Email Address:
SMS Communication Consent:
Renter's Information:
Effective Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Carrier:
Year Built:
*
Property Type:
*
Please Select
Apartment
Condo
House
Townhouse
Personal Property Amount:
*
Personal Liability Coverage:
*
Please Select
$300,000
$500,000
All Peril Deductible:
*
Please Select
$ 500
$ 1000
Security Options:
Smoke Detector
Fire/Burglar Alarm
Sprinklered
Locked Gate or Entrance
Do You Have Any Dogs?
*
Please Select
Yes
No
Breed of Dog or Dogs:
Describe any losses or claims in the past 5 years.
Submit
Should be Empty: