Krist Insurance Welcomes You! Automobile

To get a quote, please fill in the information below and then click on the SEND button. We will then contact you by e-mail, phone, or fax. Thank you!

Information about You

First Name
Last Name
Address 1
Address 2
City State Zip
E-Mail
Phone Number Fax Number:

Drivers

Driver #1:
First Name

Last Name

M F:
Marital Status:
D.O.B.
D.L. #:
Social Security #:
Good Student:
To qualify for good student must have a B average or better.

Driver #2:
First Name

Last Name

M F:
Marital Status:
D.O.B.
D.L. #:
Social Security #:
Good Student:
To qualify for good student must have a B average or better.

Driver #3:
First Name

Last Name

M F:
Marital Status:
D.O.B.
D.L. #:
Social Security #:
Good Student:
To qualify for good student must have a B average or better.

Driver #4:
First Name

Last Name

M F:
Marital Status:
D.O.B.
D.L. #:
Social Security #:
Good Student:
To qualify for good student must have a B average or better.


Accidents/ Violations/ Losses in past 3 years (5 years for major violations)

Driver #:

1

 Date:
Type:

4

 Date:
Type:

2

 Date:
Type:

5

 Date:
Type:

3

 Date:
Type:
 

 

Automobiles

Auto #1

Year:
Make:
Model:
VIN #:
Edition:
If other:
Doors:
Type:

Number of miles to Work/ School:

Auto #2

Year:
Make:
Model:
VIN #:
Edition:
If other:
Doors:
Type:

Number of miles to Work/ School:


Coverages

Current Insurance:
Policy Number:
Liability:
UM/UIM:
Med Pay:
Comp Ded:
Coll Ded:
Towing?
Rental Reimbursement?

Any other comments:

Privacy Notification

By submitting this form, you acknowledge the following: A credit report or other investigative report about you may be request in connection with this application for insurance. Any information which we have or may obtain about you or other individuals listed as policyholders on your policy will be treated confidentially.

However, this information, as well a other personal or privileged information subsequently collected, may, under certain circumstances, be disclosed without prior authorization to third parties such as to our affiliated companies for claims handling, servicing, underwriting and insurance marketing. Personal information also may be disclosed to affiliated and non-affiliated companies for non-insurance marketing purposes, unless you write to us at the address provided on this website and direct us not to make such disclosure.

You have the right to see personal information collected about you, and you have the right to correct any information which may be wrong.

If you are interested in obtaining a description of our information practices, and your rights regarding information we collect, ask your agent, or, if you have been issued a policy, please write us at the address provided with your policy.


The Krist Insurance Group, Inc. DBA Krist Insurance is a multiline Insurance Agency located in Des Moines IA. Licensed in Twelve states, The Krist Insurance Group Inc only does business where licensed. All Internet inquiries are compared to our licensed states list prior to any coverage or rate determination. If an inquiry comes from a non-licensed area, and if determined feasible, Krist Insurance Services may pursue licensing in non-licensed states prior to responding to coverage inquiries, or effecting coverage. The Krist Insurance Group, Inc. DBA Krist Insurance Services does not do business over the WEB for non- licensed states.

This material may not be published, broadcast, rewritten, or redistributed.
Copyright © 2008