Kansas Preferred Insurance Group Motorcycle Quote Sheet

Kansas Preferred Insurance Group Motorcycle Quote Sheet

913-585-1981 34102 Commerce Dr Ste B De Soto, KS 66018 www.kpigroup.net
Client Name:

First NameLast Name
Date of Birth
Driver's License Number
Spouse Name:

First NameLast Name
Date of Birth
Driver's License Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:
Email Address:
SMS Communication Consent:
Auto Information
Effective Date:

MonthDayYear
Date
Current Insurance Company:
Policy Term Length:
Billing Schedule:
Auto Coverages
Bodily Injury Limit:
Property Damage:
Underinsured/Uninsured Motorist:
Personal Injury Protection
Collision Deductible:
Comprehensive Deductible:
Motorcycle 1: VIN Number
Motorcycle 1: Coverage Requested
Motorcycle 1: Number of CC's
Motorcycle 1: Value
Motorcycle 2: VIN Number
Motorcycle 2: Coverage Requested
Motorcycle 2: Number of CC's
Motorcycle 2: Value
Motorcycle 3: VIN Number
Motorcycle 3: Coverage Requested
Motorcycle 3: Number of CC's
Motorcycle 3: Value
Describe any losses or claims in the past 5 years.
Should be Empty:

Auto Information