KBI website lead

1
Are you currently insured?* This field is required.
YESNO
2
What would you like a quote on?* This field is required.
Please Select
Auto
Life Insurance
Homeowners
Bundle Home & Auto
Renters
Bundle Renters & Auto
3
4
How many cars do you want on this policy?* This field is required.
Please Select
Please Select
1
2
3
4
5 or more
5
How many drivers are in your household?* This field is required.
Please Select
Please Select
1
2
3
4
5 or more
6
Who is your current insurance provider?* This field is required.
Please Select
Please Select
Allstate
StateFarm
Geico
Liberty Mutual
Kentucky Farm Bureau
USAA
Nationwide
Progressive
Other
7
How much are you currently paying for your auto policy?* This field is required.
Please Select
Please Select
100 - 150 Monthly
150 - 200 Monthly
200 - 250 Monthly
250 - 300 Monthly
300 or More Monthly
8
What is your street address?* This field is required.
123 ABC STREET APT #2
9
City?* This field is required.
Louisville
10
Zip code?* This field is required.
11
Approximately how old is your roof?* This field is required.
1 - 2 years old
3 - 5 years old
5-10 years old
10-15 years old
15 years old or older. (Pre 2009)
12
Are you married or single?* This field is required.Married couples with combined policies can get discounts up to 25%
MarriedSingle
13
What is your date of birth?* This field is required.
Date
Month
Day
Year
14
What is your first name?* This field is required.
15
What is your last name?* This field is required.
16
What email do you want us to send this quote to?* This field is required.
example@example.com
17
Almost finished! What is your phone number?* This field is required.
Please enter a valid phone number.
18
Any other details that are helpful?
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Large
Normal
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Ok
Ok
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