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Call us! 620-792-4515
Toll Free: 866-792-4515

Welcome
 

Request a Quote - Renters Insurance

Fill out the form and submit. We will contact you with your free, no obligation renters insurance quote.

Information provided will be kept confidential and used for quoting purposes only. All quotes are based on the information given and are subject to change upon further inspection. Coverage can not be bound via e-mail or internet service.

1911 Lakin Avenue
Great Bend, KS 67530

Phone: 620-792-4515
Fax: 620-793-3311

Email Goss Insurance

 

 

Applicant Information

Name:  
SSN:   Date of Birth:        
Street Address:  
City:   State:           ZIP:        
County:  
E-Mail Address:   
Home Phone:     Work Phone:

Residence Information

Year of Construction:
Type of Dwelling:
How Many Family Units Per Bldg:  
Type of Construction:  
  • Frame: Constructed of wood frame, covered with wood or vinyl. Less than 50% of exterior is brick or stone.
  • Masonry Veneer: 50% or more of the exterior is brick or masonry but has wood frame construction.
  • Masonry: Constructed entirely of face brick, common brick, stone or split block.
Is daycare provided on the residence premises?

Yes  No

Is residence premises within city limits

 Yes  
No
Is there a trampoline on the residence premises?

Yes  No

Is there a pool on the residence premises?

 Yes  
No
Do you own a dog(s)?

Yes  No

If yes, list breed(s)
Select all that apply::

Smoke Detectors
Monitored Alarm System
Wood Stove or any other Solid Fuel Heating Appliance
Dead Bolts
Interior Sprinkler System

Feet from home to nearest fire hydrant:
Miles to nearest fire department:

Coverage Amounts

Amount of coverage requested for personal property:  
Amount of coverage requested for personal liability:
Amount of deductible requested:

 

 

 

Phone: 620-792-4515
Toll Free: 866-792-4915
Fax: 620-793-3311

1911 Lakin Avenue
P.O. Box 1910
Great Bend, KS 67530-1910

www.gossins.com
Email Goss Insurance

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