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Gross Insurance Agency



More About Gross
Insurance Agency


Gross Insurance Agency,
has two offices located
in Ft. Thomas,KY and
Walton, KY, and has been
assisting Kentucky
residents and businesses
for over three decades.

We represent many of our
state's leading insurance
companies and provide the
service you deserve.

Remember, "every policy we sell comes with an agent!"
Call: 859-781-0434


Map & Directions to Our Main Ft. Thomas, KY Office
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On-Line Automobile
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Street Address:
City:
State: (Must be Kentucky)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
Primary Insured's Occupation:
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)


DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?
Yes No If YES to SR22 filing, why needed?
(list accident/cite)
Give details on all violations or accidents:


DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?
Yes No Comments or
Remarks?
Give details on all violations or accidents:
ADDITIONAL DRIVERS:
If More than 2 Drivers, list Additional Drivers' Names, Birthdates, and driving record history here:


VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Select Liability Limits
 
Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Rental Car &
Towing Coverage?
YES NO
 
Uninsured Motorists
Coverage?
YES NO
 
Medical and/or
PIP Coverage?
YES NO
 
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Select Liability Limits - - - Liability Limits Must
Match Vehicle #1 - - -
 
Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Rental Car &
Towing Coverage?
YES NO
 
Uninsured Motorists
Coverage?
YES NO
 
Medical and/or
PIP Coverage?
YES NO
 
Comments or Remarks:
(List additional drivers, autos, etc. here)
ADDITIONAL VEHICLES: If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:


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FT. THOMAS OFFICE: Gross Insurance Agency, LLC | 26 N Ft. Thomas Avenue - PO Box 75249 | Ft. Thomas, KY 41075-0249
Phone: 1-859-781-0434 | Fax: 1-859-781-1780 | E-Mail us at: nicholas.rolf@gross-ins.com

WALTON OFFICE: Gross Insurance Agency, LLC | 24 N Main Street - PO Box 205 | Walton, KY 41094-7107
Phone: 1-859-485-7102 | Fax: 1-859-485-7107 | E-Mail us at: patty.prather@gross-ins.com

About Us | Privacy Notice | Service Request | KY Insurance License #600690


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