Become a KwikQuotes Agent! Any fields marked with a * are required. Personal Information Name * (Last, First MI.) Zip Code * Phone * Fax Email * Professional Background Current Occupation/Title * Length of Employment * Are you self employed? * Yes No Questionnaire What brought about your interest in KwikQuotes? * Have you owned your own business previously? * Yes No If yes, explain. How soon are you looking to make the transition to KwikQuotes? * Background Information Have you ever been convicted of any offense other than minor traffic violations? * Yes No If yes, please explain. Have you ever declared personal bankruptcy? * Yes No If yes, please explain. Have you ever been or are now a party to any lawsuit? * Yes No If yes, please explain. Additional Comments Do you have any additional comments? Agreement By selecting the check box to the left, I warrant that all of the information submitted in connection with this request is true and accurate as of the date submitted; and I agree to notify KwikQuotes of any material change in my personal or business status. I understand that this request does not constitute an offer by KwikQuotes to purchase neither a territory nor Agency Office and that this information is being provided to KwikQuotes solely for the purpose of evaluating my personal and professional qualifications.