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

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First Name*
Last Name*
Email*
Phone*
Date Of Birth (MM/DD/YYYY)*
Do You Currently Have Active Policies With Us?*
For new clients home quote requests, we require auto insurance to be included in the bundle.
Preferred Contact Method
Type of Insurance*
Type of Insurance*
North Carolina Consent*
I certify that I reside in North Carolina, am relocating to the state, or own property or a registered business within North Carolina.
Terms and Conditions*
I acknowledge that by checking this box, I agree to the Privacy Policy and the Terms and Conditions of the service.
Property Address to Quote
Street Address*
Second Address Line (Suite, Apartment, or Building #)
City*
State*
Zip Code*
Is This Address Also The Mailing Address?*
Mailing Address (Street Address/City/State/Zip Code)*
Desired coverage effective date (MM/DD/YYYY)*
Homeowners Insurance
Do you currently have homeowners insurance?*
Current Insurance Company
Policy expiration date (MM/DD/YYYY)
Do you have a current homeowners insurance declaration page?*
Please upload it here:
Drop files here or

Max. file size: 59 MB.
Others Listed on Deed:*
Number Of Extra Persons Listed On Deed*
First Additional Person Listed On Deed
First Name*
Last Name*
Date Of Birth (MM/DD/YYYY)*
Second Additional Person Listed On Deed
First Name*
Last Name*
Date Of Birth (MM/DD/YYYY)*
Third Additional Person Listed On Deed
First Name*
Last Name*
Date Of Birth (MM/DD/YYYY)*
Homeowners Insurance Information
For How Long You Have Been At This Property?*
Prior Property Street Address*
Prior Property Second Address Line (Suite, Apartment, or Building #)
Prior Property City*
Prior Property State*
Prior Property Zip Code*
Is this your primary residence?*
Year property was built*
Purchase Price $
Type Of Property*
Square footage*
Number of stories*
Number of bathrooms*
Roof Type
Other Roof Type
Roof Age*
Exterior wall material (brick, siding, stucco, etc.)
Heating System*
Heating System Year Updated
Cooling System*
Cooling System Year Updated
Any galvanized, cast iron, PEX or polybutylene Pipes?
Garage type
Attached Garage Type
Basement*
Safety Features*
- Security System
- Fire Sprinkler System
- Smoke Detector
Do you own any high-value items you’d like to insure separately (jewelry, art, collectibles)?
Any recent claims in the past 5 years?*
Please describe claim*
Do you run a business from your home?*
Do you have any pets?*
How Many Pets?
First Pet's Type and Breed*
Second Pet's Type and Breed*
Third Pet's Type and Breed*
Fourth Pet's Type and Breed*
Fifth Pet's Type and Breed*
Address
Street Address*
Second Street Line (Suite, Apartment, or Building #)
City*
State*
Zip Code*
Is This Address Also The Mailing Address?*
Mailing Address (Street Address/City/State/Zip Code)*
Auto Insurance
Do You Currently Have Auto Insurance?*
Current insurance company
Policy expiration date (MM/DD/YYYY)
Desired Coverage Effective Date (MM/DD/YYYY)*
Do you have a current auto insurance declaration page?*
Please upload it here:
Drop files here or

Max. file size: 59 MB.
Coverage Limits
Liability Limits*
Other Liability Limit*
Medical Payments Coverage*
Uninsured/Underinsured Motorist Limits*
Other Uninsured/Underinsured Motorist Limits*
Number Of Vehicles*
Vehicle Information
Year/Make/Model*
Vehicle Identification Number (VIN)*
Ownership*
Primary Use*
Primary Driver*
Towing*
Extended Transportation Vehicle 1*
Extended Transportation Amount Vehicle 1*
Comprehensive Coverage?*
Comprehensive Deductible Preference*
Collision Coverage?*
Collision Deductible Preference*
Any customized equipment?*
Value of customized equipment*
Vehicle Information 2
Year/Make/Model*
Vehicle Identification Number (VIN)*
Ownership*
Primary Use*
Primary Driver*
Towing*
Extended Transportation Vehicle 2*
Extended Transportation Amount Vehicle 2*
Comprehensive Coverage?*
Comprehensive Deductible Preference*
Collision Coverage?*
Collision Deductible Preference*
Any customized equipment on second vehicle?*
Value of customized equipment*
Vehicle Information 3
Year/Make/Model*
Vehicle Identification Number (VIN)*
Ownership*
Primary Use*
Primary Driver*
Towing*
Extended Transportation Vehicle 3*
Extended Transportation Amount Vehicle 3*
Comprehensive Coverage?*
Comprehensive Deductible Preference*
Collision Coverage?*
Collision Deductible Preference*
Any customized equipment on third vehicle?*
Value of customized equipment*
Vehicle Information 4
Year/Make/Model*
Vehicle Identification Number (VIN)*
Ownership*
Primary Use*
Primary Driver*
Towing*
Extended Transportation Vehicle 4*
Extended Transportation Amount Vehicle 4*
Comprehensive Coverage?*
Comprehensive Deductible Preference*
Collision Coverage?*
Collision Deductible Preference*
Any customized equipment on fourth vehicle?*
Value of customized equipment*
Vehicle Information 5
Year/Make/Model*
Vehicle Identification Number (VIN)*
Ownership*
Primary Use*
Primary Driver*
Towing*
Extended Transportation Vehicle 5*
Extended Transportation Amount Vehicle 5*
Comprehensive Coverage?*
Comprehensive Deductible Preference*
Collision Coverage?*
Collision Deductible Preference*
Any customized equipment on fifth vehicle?*
Value of customized equipment*
Driver Information
Driver's License Number*
State of issue*
Years licensed*
Marital Status (Single / Married / Divorced / Widowed)*
Any accidents or violations in the past 5 years?*
Any additional drivers?*
How Many Additional Drivers?*
Additional Driver 1
Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 1*
Other*
Additional Driver 2
Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 2*
Other*
Additional Driver 3
Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 3*
Other*
Additional Driver 4
Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 4*
Other*
Additional Driver 5
Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 5*
Other*
Life Insurance
Do you qualify for Erie Express Life? Ages of 19 to 40 qualifies (NO MEDICAL EXAM REQUIRED).
Smoker or Non-Smoker?*
Height*
Weight*
Type of Life Insurance Policy*
Term Policy Years*
Coverage Amount $250,000, $500,000 or whatever amount preferred*
Business Insurance
Do You Currently Have Business Insurance?
Current Insurance Company
Policy Expiration Date (MM/DD/YYYY)
Do you have a current business insurance declaration page?
Please upload it here:
Drop files here or

Max. file size: 59 MB.
Effective Date (MM/DD/YYYY)*
Name of Owner*
Owner Mailing Address (Street Address/City/State/Zip Code)*
Owner Cell Phone*
Owner Email*
Additional Owner's Name (if applicable)
Additional Owner's Email (if applicable)
Name of Business*
Business DBA
Business Street Address*
Business Second Address Line (Suite, Apartment, or Building #)
Business Address City*
Business Address State*
Business Address Zip*
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)*
Safety Features
Fire Alarm
Burglar Alarm
Sprinkler System (0-100%)
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Email
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Contact

Phone: (919) 296-3787

Fax: (919) 296-3788

Email: info@affinityinsurancenc.com

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