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


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:   Licensed for cycle? YesNo
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:   Licensed for cycle? YesNo
List Tickets/Accidents last 3 yrs: What & When? 

Prior Ins, Loss free last 12 mo?YesNo    Rider Club?YesNo   Theft Alarm Credit?YesNo
Motor Vehicle or Rider Course completed?YesNo 


 Cycle Information
Vehicle 1: Year, Make Model:   Usage: 
Full Coverage?: YesNo   Veh1ID # (VIN):   cc's:
Vehicle 2: Year, Make/Model:   Usage: 
Full Coverage?: YesNo   Veh2ID # (VIN):   cc's 

Additional vehicles & drivers can be noted in message box below


Coverage Desired
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)
HomeownersLife InsuranceMedical InsuranceAnnuities
Boat InsCycle Ins Business 
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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