Auto Insurance

For an Auto Insurance Quote, please fill out the entire form below. If you encounter any issues, please call us at 913-768-0008 or info@irgks.com.

Personal Information

Name *

Company Name *

Address *

City *

State *

Zip *

Home Phone Number *

Work Phone Number *

Email Address

Have you had continuous coverage for at least 12 months? Yes No

If not, why not?

Present Insurance Company

Renewal Date

Own home? Yes No

Car #1 Information

Year

Make

Model

Type    2dr    4dr

Miles to work (one way)

Annual Mileage

Type of Anti-Thief device on vehicle

VIN #

Deductible Comprehensive    $100    $250    $500

Deductible Collision    $250    $500    $1000

Tow Yes No

Loss of use Yes No

Car #2 Information

Year

Make

Model

Type    2dr    4dr

Miles to work (one way)

Annual Mileage

Type of Anti-Thief device on vehicle

VIN #

Deductible Comprehensive    $100    $250    $500

Deductible Collision    $250    $500    $1000

Tow Yes No

Loss of use Yes No

Car #3 Information

Year

Make

Model

Type    2dr    4dr

Miles to work (one way)

Annual Mileage

Type of Anti-Thief device on vehicle

VIN #

Deductible Comprehensive    $100    $250    $500

Deductible Collision    $250    $500    $1000

Tow Yes No

Loss of use Yes No

Car #4 Information

Year

Make

Model

Type    2dr    4dr

Miles to work (one way)

Annual Mileage

Type of Anti-Thief device on vehicle

VIN #

Deductible Comprehensive    $100    $250    $500

Deductible Collision    $250    $500    $1000

Tow Yes No

Loss of use Yes No

Driver #1 Information

Driver Name

Occupation

Business

Length at current job

Highest level of education

Birth date

Drivers License #

Gender    Male    Female

Marital Status    Single    Married

Moving violations in the last 5 years    0    1    2    3+

Please provide the date and brief description of each violation.

Accidents in the last 5 years    0    1    2    3+

Please provide the date and brief description of each accident.

Driver #2 Information

Driver Name

Occupation

Business

Length at current job

Highest level of education

Birth date

Drivers License #

Gender    Male    Female

Marital Status    Single    Married

Moving violations in the last 5 years    0    1    2    3+

Please provide the date and brief description of each violation.

Accidents in the last 5 years    0    1    2    3+

Please provide the date and brief description of each accident.

Driver #3 Information

Driver Name

Occupation

Business

Length at current job

Highest level of education

Birth date

Drivers License #

Gender    Male    Female

Marital Status    Single    Married

Moving violations in the last 5 years    0    1    2    3+

Please provide the date and brief description of each violation.

Accidents in the last 5 years    0    1    2    3+

Please provide the date and brief description of each accident.

Driver #4 Information

Driver Name

Occupation

Business

Length at current job

Highest level of education

Birth date

Drivers License #

Gender    Male    Female

Marital Status    Single    Married

Moving violations in the last 5 years    0    1    2    3+

Please provide the date and brief description of each violation.

Accidents in the last 5 years    0    1    2    3+

Please provide the date and brief description of each accident.

Liability Limit for all Cars

Bodily Injury    30,000 / 60,000    50,000 / 100,000    100,000 / 300,000    250,000 / 500,000

Property Damage    25,000    50,000    100,000    500,000

Single Limit    60,000    100,000    300,000    500,000

Levels of current Uninsured Motorist coverage

Comments

Comments

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