KING & BRIM INSURANCE, INC.

Your Independent Agents For A Lifetime
 

Family-owned and operated and serving Metro Atlanta since 1953!

  Home Auto Life  
  Business Health  
  770-522-9411  



Use our SECURE site to get a quote on coverage for your home, health, auto & life.  We will NEVER sell or misuse your information.


Auto Insurance Application Information
  How did you find us?
  Policyholder:
  Phone:

Alternate Phone:   

  E-mail Address:
  Street:
  City:
 State:    Zip:
  How long have you been at this address?   
  Current Auto Insurance Company?  

Previous address IF at current address for less than 1 year:
  Street:
  City:
 State:    Zip:
  Best time to call:
 

 
  Preferred method of contact:
 

 


Please fill out the detailed information below for each driver and vehicle, then click the SUBMIT button at the bottom of the page to securely transmit the application to us.
 

Driver Information

  Driver 1 Driver 2 Driver 3
 First Name
 Date of Birth (mm/dd/yyyy)
 Driver's License #
 State of Issue
 Marital Status
 Gender
 Currently insured?
 Any accidents in the last 5 years?
Has your license been suspended or        revoked in the last 5 years?


Do any of your drivers qualify for any of these discounts?:

 

Driver Education Training

Good Student

Student more than 150 miles from home without a car

Defensive Driving Course

If you answered "Yes" to either of the three previous questions, please provide details of each incident in the comments box at the bottom of this form. 
 

Vehicle Information

 

Vehicle 1

Vehicle 2

Vehicle 3

 Year Manufactured
 Make
 Model
 V.I.N.#
 Primary Driver
 Primary Usage
 Estimated annual miles driven
Coverage Requested    
 Liability Limits
 Uninsured Motorist
 Comprehensive Deductible
 Collision Deductible
 Medical
 Towing / Labor
 Rental Reimbursement
 
Comments:
 


 
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