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*
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Are You An Active Client?*
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Type of Insurance*
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Address
Address*
Second Address Line (Suite, Apartment, or Building #)
City*
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Zip Code*
Is This Address Also The Mailing Address?*
Mailing Address*
Homeowners Insurance
Do you currently have homeowners insurance?*
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 slash DD slash YYYY
Second Additional Person Listed On Deed
First Name*
Last Name*
Date Of Birth*
MM slash DD slash YYYY
Third Additional Person Listed On Deed
First Name*
Last Name*
Date Of Birth*
MM slash DD slash YYYY
Homeowners Insurance Information
Property Address to Quote*
For How Long You Have Been At This Property?*
Prior Property Address*
Is this your primary residence?*
Do you currently live at this property?*
Year property was built*
Type Of Property*
Desired coverage effective date*
Current insurer (if applicable)
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*
Attached Garage Type
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)?
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 Currently Have Auto Insurance?*
Do you have a current auto insurance declaration page?*
Please upload it here:
Drop files here or

Max. file size: 59 MB.
Number Of Vehicles*
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
Driver's 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 Limits*
Other Liability Limit*
Uninsured/Underinsured Motorist Limits*
Other Uninsured/Underinsured Motorist Limits*
Medical Payments Coverage*
Comprehensive Coverage?*
Comprehensive Deductible Preference*
Collision Coverage?*
Collision Deductible Preference*
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 PHYSICAL REQUIRED).
- Yes
- No
Smoker or Non-Smoker?*
Height*
Weight*
Type of Life Insurance Policy*
Face Amount $250,000, $500,000 or whatever amount preferred*
Term Policy Years*
Business Insurance
Do You Currently Have Business Insurance?
Current Carrier
Do you have a current business insurance declaration page?
Please upload it here:
Drop files here or

Max. file size: 59 MB.
Effective Date*
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 1*
Business Address 2*
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)*
Alarms (Local/Central/None) Fire
Burglar
Sprinkler System (0-100%)
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Secure Quote Request

Address

Homeowners Insurance

First Additional Person Listed On Deed

Second Additional Person Listed On Deed

Third Additional Person Listed On Deed

Homeowners Insurance Information

Auto Insurance

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