Kansas Preferred Insurance Group Business Quote Sheet
913-585-1981 34102 Commerce Dr Ste B De Soto, KS 66018 www.kpigroup.net
Applicant Name:
*
Business Name:
*
FEIN (Tax ID Number):
Applicant's Date of Birth:
Business Address
*
Street Address
Street Address Line 2
City
Please Select
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Utah
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Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
SMS Communication Consent:
Type of Business Conducted:
*
Effective Date:
Legal Entity Type:
Year Business Started:
*
Number of Full Time Employees:
*
Number of Part Time Employees:
*
Gross Annual Sales:
*
Annual Employee Payroll:
*
Do You Use Subcontractors?
*
Please Select
Yes
No
Annual Cost of Subcontractors:
Do You Need A Commerical Umbrella?
*
Please Select
Yes
No
Commerical Umbrella Coverage Limit:
*
Please Select
$1,000,000
$2,000,000
$5,000,000
$10,000,000
Do You Need Cyber Liability Insurance
*
Please Select
Yes
No
Business Auto Information
Do You Have Current Coverage?
Please Select
Yes
No
Current Policy Expiration Date:
-
Month
-
Day
Year
Bodily Injury & Property Damage:
Please Select
$500,000
$750,000
$1,000,000
$2,000,000
Uninsured/Underinsured Motorist:
Please Select
$500,000
$750,000
$1,000,000
Personal Injury Protection PIP:
Please Select
Option 1: $4,500
Option 2: $10,000
Option 3: $25,000
Collision Deductible
Please Select
N/A
$500
$1,000
$2,500
$5,000
Comprehensive Deductible:
Please Select
N/A
$500
$1,000
$2,500
$5,000
Vehicle 1: VIN Number
Vehicle 1: Coverage Requested
Full Coverage
Liability Only
Rental Reimbursement
Roadside Assistance
Vehicle 2: VIN Number
Vehicle 2: Coverage Requested
Full Coverage
Liability Only
Rental Reimbursement
Roadside Assistance
Vehicle 3: VIN Number
Vehicle 3: Coverage Requested
Full Coverage
Liability Only
Rental Reimbursement
Roadside Assistance
Vehicle 4: VIN Number
Vehicle 4: Coverage Requested
Full Coverage
Liability Only
Rental Reimbursement
Roadside Assistance
Vehicle 5: VIN Number
Vehicle 5: Coverage Requested
Full Coverage
Liability Only
Rental Reimbursement
Roadside Assistance
Driver's Information
Driver 1:
First Name
Last Name
Date of Birth:
Driver's License Number:
Driver 2:
First Name
Last Name
Date of Birth:
Driver's License Number:
Driver 3:
First Name
Last Name
Date of Birth:
Driver's License Number:
Driver 4:
First Name
Last Name
Date of Birth:
Driver's License Number:
Driver 5:
First Name
Last Name
Date of Birth:
Driver's License Number:
Submit
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