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

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%)
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Secure Quote Request

Property Address to Quote

Homeowners Insurance

First Additional Person Listed On Deed

Second Additional Person Listed On Deed

Third Additional Person Listed On Deed

Homeowners Insurance Information

Address

Auto Insurance

Coverage Limits

Vehicle Information

Vehicle Information 2

Vehicle Information 3

Vehicle Information 4

Vehicle Information 5

Driver Information

Additional Driver 1

Additional Driver 2

Additional Driver 3

Additional Driver 4

Additional Driver 5

Life Insurance

Business Insurance

Safety Features