Welcome to the Cardinal & Universal Insurance Agency - Insurance request System.
Our market area is 30 miles around Manhattan & Junction City, Ks.

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Personal Information
Name: 
Address:(street,city, state,zip): 
Phone:    EMAIL:

Driver 1 Name:   Date of Birth(mm/dd/yy):   Sex: MaleFemale
Soc Sec No:    Occupation:  Kansas DL?: YesNo
Drivers License No:    Drivers License State:  
List Tickets/Accidents last 3 yrs: What & When?  

Driver 2 Name::   Date of Birth(mm/dd/yy):   Sex: MaleFemale
Soc Sec No:      Occupation:  Kansas DL?: YesNo
Driver License No:    Drivers License State:  
List Tickets/Accidents last 3 yrs: What & When? 

Prior Ins, Loss free last 12 mo?YesNo   
Boat Safety Course completed?YesNo 

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Boat Information
Boat 1: Year, Make Model:   Market value:  
Full Coverage?: YesNo>  Veh1ID #(VIN):  HP in I/O:

Motor:(if Outboard) Year,Make/Model:   Market Value: 
Full Coverage?: YesNo  MotID #(VIN):   HP 

Trailer:Year,Make/Model:   Market value: 
Full Coverage?: YesNo   ID #(VIN):  

Additional vehicles &drivers can be noted in message box below
Coverage Desired

Bodily Injury Liability:	25/50 50/100 100/300 250/500
Uninsured Motorist:	25/50 50/100 100/300 250/500
Property Damage:	25 50 100 300
PIP:	No pip BASIC 4500 12500 50000
Collision Deductible:	500 100 250 1000 NONE
Comprehensive Deductible:	500 100 250 1000 NONE
Rental:	None $15 $30
Towing:	None $15 $30

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Are you interested in any of our other Products? (check all that apply)
HomeownersLife InsuranceMedical InsuranceAnnuities
Boat InsCycle Ins Business 

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Any Message? Questions? Special Considerations?

To get the best rates and most accurate quotes for you some of our companies use consumer reports which may contain credit information to develop a rate. If for some reason you do not wish us to use these companies, please let us know.

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