Fuqua Insurance

Auto Insurance Quote Request
Please note:  We are only licensed to serve customers in Kansas.  If you are not currently a resident of Kansas, we appreciate your interest, but are unable to serve you at this time.
 
Personal Information:
Name:
Address (street, city, state, zip):
Phone:    E-Mail: 
  
Driver 1:
Date of Birth (mm/dd/yy):    Sex: Male   Female
Social Security Number:   Drivers License #:
List Tickets/Accidents during last 3 years:
Current/Prior Insurance Co?
Home Owner? Yes   No
Occupation:
  
Driver 2:
Date of Birth (mm/dd/yy):    Sex: Male   Female
Social Security Number:   Drivers License #:
List Tickets/Accidents during last 3 years:
Current/Prior Insurance Co?
Home Owner? Yes   No
Occupation:
 

Vehicle Information:
Vehicle 1:
Year, Make, Model:
Primary Use:
Do you want Full Coverage? Yes   No
  
Vehicle 2:
Year, Make, Model:
Primary Use:
Do you want Full Coverage? Yes   No
 
(Additional vehicles can be listed in the "Questions & Comments" text box below)
 

Coverage:

  
  Bodily Injury Liability:
  Uninsured Motorist:
  Property Damage:
  PIP:
  Collision Deductible:
  Comprehensive Deductible:
  Rental:
  Towing:
 

Are you interested in any of our other Products?
(check all that apply)
Homeowners Life Insurance Medical Insurance Annuities
Boat Insurance Motorcycle Insurance Business Insurance
 

Other Questions or Comments?