Name: Affinity Insurance Group
Address: 800 W Williams St, Apex, NC, 27502, US
Telephone: (919) 296-3787

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Full Name*
Email*
Phone (Optional)
Date of Birth*
Are You An Active Client?*
Type of Insurance*
Consent*
I certify that I reside in North Carolina, am relocating to the state, or own property or a registered business within North Carolina. I acknowledge that by checking this box, I agree to the Privacy Policy and the Terms and Conditions of the service.
Homeowners Insurance
Do you have a current homeowners insurance declaration page?*
Please upload it here:
Drop files here or

Max. file size: 59 MB.
Preferred Contact Method
Others Listed on Deed:*
Full Name*
Property Address to Quote*
For How Long You Have Been At This Property?*
Prior Property Address*
City*
State*
Zip Code*
Is this your primary residence?*
Do you currently live at this property?*
Year property was built*
Type Of Property*
Desired coverage effective date*
Do you currently have homeowners insurance?*
Current insurer (if applicable)
Square footage*
Number of stories*
Number of bedrooms*
Number of bathrooms*
Roof type and age*
Exterior wall material (brick, siding, stucco, etc.)
Heating and cooling systems (type and age)*
Any galvanized, cast iron, PEX or polybutylene Pipes
Garage type
Attached Garage Type
Basement*
Smoke Detector*
Security system*
Fire sprinkler system*
Do you own any high-value items you’d like to insure separately (jewelry, art, collectibles)?
Do you have any pets?*
Pet's Type and Breed*
Any recent claims in the past 5 years?*
Please describe claim*
Do you run a business from your home?*
Auto Insurance
Do you have a current auto insurance declaration page?*
Please upload it here:
Drop files here or

Max. file size: 59 MB.
Address*
City*
State*
Zip Code*
Preferred Contact Method
Number Of Vehicles Quoting*
Vehicle Information
Year*
Make*
Model*
Vehicle Identification Number (VIN)*
Ownership (Owned / Financed / Leased)*
Primary Use (Commute / Pleasure / Business)*
Primary Driver*
Annual Mileage*
Any customized equipment?*
Value of customized equipment*
Towing*
Extended Transportation*
Vehicle Information 2
Year*
Make*
Model*
Vehicle Identification Number (VIN)*
Ownership (Owned / Financed / Leased)*
Primary Use (Commute / Pleasure / Business)*
Primary Driver*
Annual Mileage*
Any customized equipment on second vehicle?*
Value of customized equipment*
Towing*
Extended Transportation*
Vehicle Information 3
Year*
Make*
Model*
Vehicle Identification Number (VIN)*
Ownership (Owned / Financed / Leased)*
Primary Use (Commute / Pleasure / Business)*
Primary Driver*
Annual Mileage*
Any customized equipment on third vehicle?*
Value of customized equipment*
Towing*
Extended Transportation*
Vehicle Information 4
Year*
Make*
Model*
Vehicle Identification Number (VIN)*
Ownership (Owned / Financed / Leased)*
Primary Use (Commute / Pleasure / Business)*
Primary Driver*
Annual Mileage*
Any customized equipment on fourth vehicle?*
Value of customized equipment*
Towing*
Extended Transportation*
Vehicle Information 5
Year*
Make*
Model*
Vehicle Identification Number (VIN)*
Ownership (Owned / Financed / Leased)*
Primary Use (Commute / Pleasure / Business)*
Primary Driver*
Annual Mileage*
Any customized equipment on fifth vehicle?*
Value of customized equipment*
Towing*
Extended Transportation*
Driver Information
License Number*
State of issue*
Years licensed*
Marital Status (Single / Married / Divorced / Widowed)*
Currently insured?*
Current insurance company (if applicable)
Policy expiration date
Any accidents or violations in the past 5 years?*
Desired Coverage Effective Date*
Liability Coverage Amount (State Minimum / $50,000/$100,000/$50,000 / $100,000/$300,000/$100,000 / $250,000/$500,000/$100,000)
Comprehensive Coverage?*
Collision Coverage?*
Comprehensive Deductible Preference*
Collision Deductible Preference*
Any additional drivers?*
How many additional drivers?*
Additional Driver 1
Name*
License Number*
State of issue*
Additional Driver 2
Name*
License Number*
State of issue*
Additional Driver 3
Name*
License Number*
State of issue*
Additional Driver 4
Name*
License Number*
State of issue*
Additional Driver 5
Name*
License Number*
State of issue*
Life Insurance
Do you qualify for Erie Express Life? Ages of 19 to 40 qualifies (NO PHYSICAL REQUIRED).
- Yes
- No
Address*
City*
State*
Zip Code*
Preferred Contact Method
Smoker or Non-Smoker?*
Height and Weight*
Term Insurance or Whole Life *
Face Amount $250,000, $500,000 or whatever amount preferred*
Term Policy 10, 15, 20 or 30 years*
Business Insurance
Do you have a current business insurance declaration page?
Please upload it here:
Drop files here or

Max. file size: 59 MB.
Effective Date*
Current Carrier
Name of Owner*
Owner Mailing Address*
Owner Cell Phone*
Owner Email*
Additional Owner's Name (if applicable)
Additional Owner's Email (if applicable)
Name of Business*
Business DBA
Business Address*
Business Phone
Website (if applicable)
Federal Tax ID or SSN*
Business Entity (LLC, Corp, S-Corp, Sole Prop)*
Type of Business (Brief Description)*
Years in Business*
Years Experience in the field*
Gross Sales (est.)*
Annual Payroll (est.)*
Business Personal Property Coverage ($)
Number of Full Time Employees*
Number of Part-Time Employees*
Percentage of Work Subcontracted
Building Coverage*
Building Value ($)
Building Sq. Ft. (or rental space sq ft)*
Alarms (Local/Central/None) Fire
Burglar
Sprinkler System (0-100%)
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