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 Kentucky Farm Bureau Kentucky Farm Bureau Insurance
 Insurance Services   

    Quote: Automobile Insurance

If you live in the Lexington/Fayette County (KY) area, or are planning to move here, just fill in this simple form. We'll be glad to contact you at a convenient time to discuss your needs.
  

Please Note:
We can only quote insurance rates if you live in the
Lexington/Fayette County, KY area. 

This information for use by KFB only.

Name: 
Street: 
City:    State:   Zip:
When is the best time to call? 
Phone: (888-888-8888)
E-mail Address:

1. Current Auto Insurance Company: 

      Policy Number: 

2. Have you ever been insured with Kentucky Farm Bureau before? Yes  No

     a.   If Yes, name of person insured: Date:

3. How did you hear about Kentucky Farm Bureau?

4. Have you or any driver or member of your household:

a. Had a ticket for any of the following moving traffic violations: Yes No Date (Mo/Day/Yr)
     Speeding

     Driving while intoxicated or under influence of drugs
     Reckless driving
     Improper driving of any nature
     Other (describe):
    
b. Ever been charged with a non-motor vehicle offense?
c. Had insurance cancelled or refused?
d. Had a driver's license suspended or revoked?
e. Been involved in a vehicle accident in the last 5 years?
f. Had glass breakage loss or hail damage loss?

      At Fault     Not at Fault

5. Describe any physical or mental impairment:
    

6. How many persons in your household? 

7. List the following for each driver:

Name

 Date of Birth # Years Lics'd Name & Address of Employer How
Long Employed?		 Miles
Driven
Work/
School 		 Vehicle Principally Driven

Drivers Lic #:
Married:
Y N
Yrs.

Drivers Lic #:
Married:
Y N
Yrs.

Drivers Lic #:
Married:
Y N
Yrs.

Drivers Lic #:
Married:
Y N
Yrs.

8. List names and date of birth for household members over 15 years old, but NOT licensed to drive:

Name

 Date of Birth

 9. List all vehicles owned in your household:

Year

 Make Model VIN Number Titleholder Where Garaged

10. How long have you lived at your current address?  Years
      If less than 3 years, give previous address:

11. Do you   Own     Rent     
       If Own, how many acres?

12. What are your current limits of liability?
Bodily injury:    Property damage:

By checking below I certify that I have answered all questions in truth and to the best of my knowledge. I understand that findings to the contrary to the above could jeopardize my coverage, resulting in higher rates or cancellation.
    Yes    No

This request is not an application, contract, or binder of coverage. An application must be completed and signed and premium paid by you before coverage is binding. All coverages are subject to the terms and conditions contained in our policies and endorsements.