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Coverage Kentuckians count on.

At Kentucky Farm Bureau, we deliver the protection and peace of mind you deserve, the first-rate service you expect, and unmatched
claims response if the unexpected should happen. That’s what makes us Kentucky’s insurance company.

Personal Information

This information is for internal use only. Kentucky Farm Bureau treats this information as confidential and does not disclose it to third parties unless necessary to process a transaction, service an account, or as otherwise provided by law.

First Name:
Last Name:
Phone Number:
Email Address:
Street Address:
Street Address 2:
City:
State:
Zip Code:

Preferred Method of Contact:

Phone

Either

Best Time(s) to Contact:

Morning

Afternoon

Night

Insurance Product(s) Interested In:

*Life insurance products provided by Southern Farm Bureau® Life Insurance Company, Jackson, MS.

Vehicles
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For your vehicle insurance needs, do you have an active insurance policy?

Vehicles

Vehicle Information (1)

Year

Make

Model

Vin Number

Requested Liability Limits (same for all vehicles) - Physical Damage

Collision:

Other Than Collision:

Other Coverage Options:

Add Vehicle

Remove Vehicle

Auto Drivers

Driver Information (1)

Fill from Step 1
First Name:
Last Name:
Gender:
Married:
Date of Birth:
Drivers License #:
State:
Name of Employer:
Annual Miles Driven:
Primary Vehicle:	(from numbered list above)

Add Driver

Remove Driver

Fill from Step 1
Owner's First Name:
Owner's Last Name:
Date of Birth:
Gender:
Street Address:
Street Address 2:
City:
State:
Zip:
Type of Home:
Construction Type:
Lot Size in approximate acres:
Construction Year:
Requested Coverage on Dwelling:	$
Farm?
Does the total value of structures not attached to the dwelling exceed: $
What is the total approximate value of those outbuildings? $
Deductible:

It looks like you missed something on the form.

Eligibility for our insurance products requires Kentucky residency or property/vehicle ownership in Kentucky.

Collision Insurance covers damage to your car when involved in a collision.

Disclaimer: This description is for information only. It is not intended to be a legal explanation of a policy contract. You must refer to your policy for specific language and coverage clarification.

Other Than Collision Insurance provides coverage for physical damage to your car for other than collision claims such as fire, theft, vandalism, and collision with animal, etc.

You can request additional coverage options on your auto policy, such as medical, transportation expense, towing and labor, etc. An agent will be glad to discuss additional coverage options that are available.

Masonry veneer would include homes where are least 60% of the exterior is brick, stone, stucco, or block.

Frame includes vinyl, aluminum, cedar plank, or other similar exterior coverings, which do not fit in the masonry veneer class.

Additional details include things like vehicle make and model, driver info, drivers license number, type of home, lot size, coverage needs, etc.