Affordable Insurance Services

Hours of Operation:
Monday - Friday
9:00 a.m. to 6:00 p.m.
Saturday
9:30 a.m. to 3 p.m.
Phone: 913-722-2111
Fax: 913-722-6307
Location:
7800 Shawnee Mission Parkway, Suite 12, Overland Park, KS 66202

Home / Dwelling Quote - MISSOURI OR KANSAS RESIDENTS

We would appreciate it if you would take a few moments to answer the following questions. Please be assured that we do not share or sell personal information about you except when we have your permission.

First Name

M.I.

Last Name

Bold = Required field

DOB

SS#

Address

City

State

Zip Code

Spouse

M.I.

Last Name

Phone (Home)

Phone (Work)

County

Occupation

Length of Employment

How long at this address?

Property Address if not the same above:

Amount of Insurance:

Years of Construction

Construction

Style House:

Basement SQ FT

Basement Finished/Unfinished?

Finished

Unfinished

Garage:

#of car garage:

#of Bedrooms:

#of Full Baths:

#of Feet to Hydrant:

#of Half Baths:

#of Miles to Fire Station:

If located outside city limits what station services?

Store

#of Chimneys

Type of Furnace

Central Air Conditioning

Yes

Upgrading

What Year?

Same duct as heat:

Yes

Deadbolts

Fire Extinguishers

Smoke Detectors

Neighborhood Watch Program

Alarm Systems

Occupied 24hrs a day?

Square Feet of Living Area Ground Level:

Are You?

Pet Kind (SPECIFIC)?

Swimming Pool

Are they fenced and locked?

Yes

Any scheduled item (Jewelry, furs, computers, etc) item & value

PRIOR INS CARRIER

Credit Status?

Any prior losses?
(date,, amount of loss, and exact details)

Expires:

DISCOUNTING