Kentucky Auto Insurance Quote from Gross Insurance Agency, Inc.

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Gross Insurance Agency, Inc.
26 North Ft. Thomas Avenue
PO Box 75249
Ft. Thomas, KY 41075-0249
Phone: 1-859-781-0434
Fax: 1-859-781-1780
E-Mail us at: Gross_Ins@yahoo.com

On-Line Automobile Insurance Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name:
Street Address:
City:
State: (Must be Kentucky)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):

Marital Status: Single Married	Homeowner? Yes No

Currently Insured? (If yes, list carrier, and # of years continuous. If none, type N/C)

How is Your Credit History? (Some carriers use credit history to qualify)

DRIVER INFORMATION #1
Name:		Birthdate:
Sex (M/F):		# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:		Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	If YES to SR22 filing, why needed? (list accident/cite)

DRIVER INFORMATION #2 (if none, leave blank)
Name:		Birthdate:
Sex:		# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:		Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	Comments or Remarks?

VEHICLE #1 INFORMATION (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle:		Make & Model:
Annual Mileage:		Used in business? (Explain, if yes):
VEHICLE #1 COVERAGES:
Limits of Liability:	$100/300 BI / 100 PD $250/500 BI / 100 PD $300,000 CSL $500,000 CSL $1 Million + (Quote Umbrella)

Comprehensive Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Collision Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Rental Car & Towing Coverage?	YES NO

VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:		Make & Model:
Annual Mileage:		Used in business? (Explain, if yes):
VEHICLE #2 COVERAGES:
Limits of Liability:	$100/300 BI / 100 PD $250/500 BI / 100 PD $300,000 CSL $500,000 CSL $1 Million + (Quote Umbrella)

Comprehensive Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Collision Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Rental Car & Towing Coverage?	YES NO

Comments or Remarks: (List additional drivers, autos, etc. here)

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