Key Insurance Services, Inc.

Quotes only available to WISCONSIN residents

Please fill in your personal information and information for the type of insurance you are requesting a quote for. You can request more than one type of insurance quote using this form. Thank you for taking your time to work with Key Insurance Services.

Personal Information

Name:
Address:
Suite/Apt #:
City:	State Zip
Home Phone:	Best time to call
Work Phone:	Best time to call
Fax:	Email address:
Contact me via: home phone work phone email fax

Automobile Insurance Information

When does your current auto insurance policy expire?
Who is your current auto insurance carrier (not agency)?

Vehicle Information

#	Year	Make	Model	Vehicle Identification Number
1
2
3
4

Vehicle Usage and Coverage

#	Usage	If used for work mileage one-way	Comprehensive Deductible	Collision Deductible	Bodily Injury/ Property Damage
1
2
3
4

Driver Information

Driver 1

Name	Birthday	Sex
		Male Female
Marital Status	Drivers License Number	Social Security Number

Violations/Accidents
(types & date)

Driver 2

Name	Birthday	Sex
		Male Female
Marital Status	Drivers License Number	Social Security Number

Violations/Accidents
(types & date)

Driver 3

Name	Birthday	Sex
		Male Female
Marital Status	Drivers License Number	Social Security Number

Violations/Accidents
(types & date)

Driver 4

Name	Birthday	Sex
		Male Female
Marital Status	Drivers License Number	Social Security Number

Violations/Accidents
(types & date)

Please list any special coverage or discounts that apply to any driver or vehicle:

Life Insurance

	Marital Status	Smoker	Date of Birth	Amount of Insurance	Type of Insurance
Insured		Yes No
Spouse		Yes No

Are You interested in any of the following:

Disability income coverage? Yes No
Long Term Care insurance? Yes No

Homeowners Insurance

Do you currently have homeowners insurance?

Yes No If yes, policy expiration date

If you own your home please answer the following questions:

Current Insurance Value:

Year home was built:

Construction type:

Do you have a wood burning stove: Yes No

Does your home have business exposure: Yes No

Coverage Amounts:

Property Deductible:

Personal Liability Limit:

If you rent your home please answer the following questions:

Replacement cost value of personal items:

Coverage Amounts:

Rental policy property deductible:

Rental Policy personal liability limit:

Business Insurance

To help us determine your business insurance needs please answer the following questions:

Do you currently have business insurance?

Yes No If yes, policy expiration date

Describe the type of business you are engaged in:

Number of Employees: Annual sales in dollars: