New Client Auto Insurance Check List
This form is for new clients of K&A. If any question does not apply to you please type N/A
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Email *
First, Last *
Cell Number *
DOB *
MM
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DD
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YYYY
Have you had any previous claims in the last 3 years? *
Required
Do you currently have auto insurance? *If not skip to question #10* *
If you selected yes please send a copy of your declaration page.
Required
Who is your current insurance provider?
How much is your current monthly premium?
When does your policy expire?
MM
/
DD
/
YYYY
Year, Make Model *please list all cars* *
What is your VIN # of your vehicle? *please list all VIN #'s in order of car list* *
Address *city, state, zip* *
Are you a homeowner? *
Will there be someone else added on this policy? *if no skip to the next question* *
Required
2nd Driver (First, Last) & DOB
Coverage Options *
If you do not want comp/collision together please let us know.
Required
How did you hear about us or who referred you? *
K&A Mobile Tax Services may occasionally have products or services that we think may interest you. By checking this box and using this form you give us consent to use automated technology to call and text you at the phone number(s) above, including your wireless number if provided. Please note that you are not required to provide this consent to make a purchase from us. *
Signature *
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