Quote Forms

For a quote please print this page, complete this form and fax it to us at 606-478-9510 or you can call us toll free at 1-800-788-4397 or   
606-478-9500                                                                                                                                                      

NAME:_____________________________EMAIL:___________________________

PHONE:_______________________________________PAPERLESS: Y or N

P.O.Box____________AND/OR PHYSICAL__________________________________

CITY: _________________/____________________KY ZIP CODE:_______/_______

ARE ALL VEHICLES KEPT AT THE PHYSICAL ADDRESS: Y OR N

CITY LIMITS: Y OR N                                                             CHECKING ACCOUNT: Y OR N

PRIOR INS: ______________________LIMITS: ______________EXP: ___________

HOW LONG HAVE YOU HAD YOUR PRIOR INS:_____________________________

OWN HOME:______ OWN MOBILE HOME__________

RENT_________ OTHER:________________________________________________

LENGTH OF TIME AT CURRENT RESIDENCE: ______________________________

PRIOR ADDRESS (if less than 2 months):______________________________________

MILES TO WORK/SCHOOL (ONE WAY): ________OCCUPATION: _______________

HAS DRIVERS BEEN LICENSED MORE THAN 3 YRS: Y OR N

NUMBER OF PEOPLE LIVING IN YOUR HOUSEHOLD: __________

DRIVERS:

VEHICLES:

UM: Y or N UIM: Y or N

ACCIDENTS/VIOLATIONS LAST 3 TO 5 YEARS