Rich Bales

809 8th St, SW, Suite D
Altoona, IA 50009
Phone: 515-978-9143

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Please select the type of policy you would like a quote for. You will be shown a specialized form for that product.

Commercial Insurance

Personal Insurance

Auto Insurance

Please complete the form below to receive an auto insurance quote from Phillips Stafford Insurance Group. You can complete as much or as little of the information as you would like. We can always give you a call to gather the missing information. The more complete information we receive the faster we can prepare a quote for you. We make it our goal to get back to you within 1 business day.

1General Info

2Drivers

3Vehicles

4Policy Coverages

5Underwriting Questions

6Submit

Name*
First Last
Phone*
Email*
Preferred Contact Method*
- Phone
- Email
Would you like to package your auto insurance?
Check all that apply
- Package with Home
- Package with Toy (motorcycle, ATV , Snowmobile, RV, etc)
- Package with Umbrella
Please chose your preference*
- Please call me to gather my personal information
- I would like to fill out my personal information here for a faster quote
Please include as little or as much additional information as you would like. We will contact you to gather any additional information we need.
Address
Street Address Address Line 2 City State ZIP Code

Driver Information
How many total drivers will be on the policy?
Driver 1
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 2
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 3
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 4
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 5
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 6
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY

Vehicle Section
How many vehicles do you need to insure?
Vehicle 1
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 2
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 3
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 4
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 5
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 6
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 7
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Vehicle 8
VIN
---OR---
Year
Make
Model
Vehicle Use
Commute- This vehicle is used to commute to and from work, among other uses.
Business- This vehicle is used for a business, like a realtor, salesman, or contractor
Pleasure- This vehicle is used strictly for pleasure. For example, a sports car used for fun or a extra used as a spare
Farm- This vehicle is used primarily to work on a farm
Approximate one-way commute distance (miles)
What type of business is the car used for?
Comprehensive Deductible
Collision Deductible
Rental Reimbursement

Toy Insurance

Please complete the form below to receive a toy insurance quote from Phillips Stafford Insurance Group. You can complete as much or as little of the information as you would like. We can always give you a call to gather the missing information. The more complete information we receive the faster we can prepare a quote for you. We make it our goal to get back to you within 1 business day.

1Contact Info

2Driver Info

3Vehicle info

4Policy Coverages

5Underwriting Questions

6Submit

Name*
First Last
Phone*
Email*
Preferred Contact Method*
- Phone
- Email
Would you like to package your toy insurance?
Check all that apply
- Package with Auto
- Package with Home
- Package with Umbrella
Please chose your preference*
- Please call me to gather my personal information
- I would like to fill out my personal information here for a faster quote
Please include as little or as much additional information as you would like. We will contact you to gather any additional information we need.
Address
Street Address Address Line 2 City State ZIP Code

Driver Information
How many total drivers will be on the toy policy?
Driver 1
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 2
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 3
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Providing a social security number will help us prepare a more exact quote by allowing us to order an insurance score and driving record. Our website is protected with 128-bit encryption to ensure your personal information is kept safe. If you would prefer, you can leave this information out and we can collect it from you via a phone call at a later time.
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 4
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY
Driver 5
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
What state issued this driver's license?
Social Security Number (optional)
Why do you request this?
Providing a social security number will help us prepare a more exact quote by allowing us to order an insurance score and driving record

Is it safe?
Our website is protected with 128 bit encryption to ensure your personal information is kept safe.

If you would prefer, you can leave this information out and we can collect it from you via a phone call at a later time.
Good Student?
Is this driver under the age of 25, enrolled in school, and maintains a 3.0GPA?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY

Date can be approximate. Format: mm/dd/yyyy
Incident 2
Incident 2 Date
MM slash DD slash YYYY

Date can be approximate. Format: mm/dd/yyyy
Incident 3
Incident 3 Date
MM slash DD slash YYYY

Date can be approximate. Format: mm/dd/yyyy
Incident 4
Incident 4 Date
MM slash DD slash YYYY

Date can be approximate. Format: mm/dd/yyyy
Incident 5
Incident 5 Date
MM slash DD slash YYYY

Date can be approximate. Format: mm/dd/yyyy
Incident 6
Incident 6 Date
MM slash DD slash YYYY

Date can be approximate. Format: mm/dd/yyyy
Incident 7
Incident 7 Date
MM slash DD slash YYYY

Date can be approximate. Format: mm/dd/yyyy
Incident 8
Incident 8 Date
MM slash DD slash YYYY

Date can be approximate. Format: mm/dd/yyyy
Driver 6
Name
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Drivers License State
Social Security Number (optional)
Good Student?
Married/Single
How many violations in the last 3 years or accidents in the last 5 has this driver had?
Incident 1
Incident 1 Date
MM slash DD slash YYYY
Incident 2
Incident 2 Date
MM slash DD slash YYYY
Incident 3
Incident 3 Date
MM slash DD slash YYYY
Incident 4
Incident 4 Date
MM slash DD slash YYYY
Incident 5
Incident 5 Date
MM slash DD slash YYYY
Incident 6
Incident 6 Date
MM slash DD slash YYYY
Incident 7
Incident 7 Date
MM slash DD slash YYYY
Incident 8
Incident 8 Date
MM slash DD slash YYYY

Vehicle Section
How many toys do you need to insure?
Vehicle 1
VIN
Year
Make
Model
Vehicle type
Comprehensive Deductible
Collision Deductible
Approximate Value
Vehicle 2
VIN
Year
Make
Model
Vehicle Type
Comprehensive Deductible
Collision Deductible
Approximate Value
Vehicle 3
VIN
Year
Make
Model
Vehicle Type
Comprehensive Deductible
Collision Deductible
Approximate Value
Vehicle 4
VIN
Year
Make
Model
Vehicle Type
Comprehensive Deductible
Collision Deductible
Approximate Value
Vehicle 5
VIN
Year
Make
Model
Vehicle Type
Comprehensive Deductible
Collision Deductible
Approximate Value
Vehicle 6
VIN
Year
Make
Model
Vehicle Type
Comprehensive Deductible
Collision Deductible
Approximate Value
Vehicle 7
VIN
Year
Make
Model
Vehicle Type
Comprehensive Deductible
Collision Deductible
Approximate Value
Vehicle 8
VIN
Year
Make
Model
Vehicle Type
Comprehensive Deductible
Collision Deductible
Approximate Value

Health Insurance

Please complete the form below to receive a health insurance quote from Phillips Stafford Insurance Group. We will shop multiple health insurers and find the best rates for you.

1Basic Info

2Insured Info

3Submit

Name*
First Last
Phone Number*
Email*
Zip Code*
County*
Preferred Contact Method*
- Phone
- Email
Please select your preference*
- Please call me to discuss my health insurance needs
- I'd like to complete the form to receive a faster quote

Will this plan be for an individual or a family?
- Individual
- Family
Individual Quote
Name of person to be insured
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Do you use tobacco?
Family Quote
How many total people in the family will be on the plan?
1st Insured
Name of person to be insured
First Last
Gender
Date of Birth
MM slash DD slash YYYY
Does this person use tobacco?
2nd Insured
Name of person to be insured
First Last
Relationship to 1st Insured
Gender
Date of Birth
MM slash DD slash YYYY
Does this person use tobacco?
3rd Insured
Name of person to be insured
First Last
Relationship to 1st Insured
Gender
Date of Birth
MM slash DD slash YYYY
Does this person use tobacco?
4th Insured
Name of person to be insured
First Last
Relationship to 1st Insured
Gender
Date of Birth
MM slash DD slash YYYY
Does this person use tobacco?
5th Insured
Name of person to be insured
First Last
Relationship to 1st Insured
Gender
Date of Birth
MM slash DD slash YYYY
Does this person use tobacco?
6th Insured
Name of person to be insured
First Last
Relationship to 1st Insured
Gender
Date of Birth
MM slash DD slash YYYY
Does this person use tobacco?
7th Insured
Name of person to be insured
First Last
Relationship to 1st Insured
Gender
Date of Birth
MM slash DD slash YYYY
Does this person use tobacco?
8th Insured
Name of person to be insured
First Last
Relationship to 1st Insured
Gender
Date of Birth
MM slash DD slash YYYY
Does this person use tobacco?

Disability Insurance

Please complete the quote below to receive a quote on Disability Income Insurance. We make it our goal to get back to you within one business day.

1Contact Info

2Personal Info

3Health Info

4Submit

Name*
First Last
Phone Number*
Email*
Prefered Contact Method*
- Phone
- Email
Please chose your preference*
- Please call me to discuss my Disability Income Needs
- I'd like to complete the form to get a faster quote

Long Term Care Insurance

Please complete the form below to receive a Long Term Care Insurance quote from Phillips Stafford Insurance Group. The information you provide will help us be better prepared to discuss your unique needs when we contact you. Our goal is to respond within 1 business day.

1Contact Info

2Personal Info

3Policy Questions

4Submit

Name*
First Last
Phone Number*
Email*
Prefered Contact Method*
- Phone
- Email
Please chose your preference*
- Please call me to discuss my Long Term Care Insurance Needs
- I'd like to complete the form to get a faster quote

Health Questions
Height
Weight
Are you currently using oxygen, a wheelchair, crutches or cane, or receiving physical therapy?
Are you currently in a nursing home or receiving home health care?
Have you applied for or are you eligible for Medicaid?
Have you had any surgery scheduled or have you been recommended to have surgery?
Are you currently working?
Are you currently on disability?
Have you used tobacco in the last 3 years?
Have you been declined or rated for LTC insurance in the past?
Have you been hospitalized in the past 10 years?
Have you received treatment for any medical condition in the last 10 years?
Are you currently taking any medications?
Please explain any yes answers above
Information for joint applicant
Date of Birth*
MM slash DD slash YYYY
Gender
Resident State
Health Questions
Height
Weight
Are you currently using oxygen, a wheelchair, crutches or cane, or receiving physical therapy?
Are you currently in a nursing home or receiving home health care?
Have you applied for or are you eligible for Medicaid?
Have you had any surgery scheduled or have you been recommended to have surgery?
Are you currently working?
Are you currently on disability?
Have you used tobacco in the last 3 years?
Have you been declined or rated for LTC insurance in the past?
Have you been hospitalized in the past 10 years?
Have you received treatment for any medical condition in the last 10 years?
Are you currently taking any medications?
Please explain any yes answers above

Rich Bales

Please select the type of policy you would like a quote for. You will be shown a specialized form for that product.

Commercial Insurance

Due to the size, detail, and intricacies of a business insurance policy, we prefer to talk with you about your operation before preparing a quote. But you can start the conversation by completing the form below. Our goal is to have a business insurance specialist contact you within 1 business day.

Due to the size, detail, and intricacies of a business insurance policy, we prefer to talk with you about your operation before preparing a quote. But you can start the conversation by completing the form below. Our goal is to have a business insurance specialist contact you within 1 business day.

Due to the size, detail, and intricacies of a business insurance policy, we prefer to talk with you about your operation before preparing a quote. But you can start the conversation by completing the form below. Our goal is to have a business insurance specialist contact you within 1 business day.

Due to the size, detail, and intricacies of a business insurance policy, we prefer to talk with you about your operation before preparing a quote. But you can start the conversation by completing the form below. Our goal is to have a business insurance specialist contact you within 1 business day.

Due to the size, detail, and intricacies of a business insurance policy, we prefer to talk with you about your operation before preparing a quote. But you can start the conversation by completing the form below. Our goal is to have a business insurance specialist contact you within 1 business day.

Personal Insurance

Driver Information

Driver 1

Driver 2

Driver 3

Driver 4

Driver 5

Driver 6

Vehicle Section

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Vehicle 7

Vehicle 8

Policy Level Coverages

Underwriting Questions

Second Insured Information

Home and Condo/Townhouse coverages

Renters Insurance Coverages

Optional Coverages

Driver Information

Driver 1

Driver 2

Driver 3

Driver 4

Driver 5

Driver 6

Vehicle Section

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

Vehicle 7

Vehicle 8

Policy Level Coverages

Underwriting Questions

Please complete the information below to receive an accurate quote

Requested policy info

Optional Policy Features

Individual Quote

Family Quote

1st Insured

2nd Insured

3rd Insured

4th Insured

5th Insured

6th Insured

7th Insured

8th Insured

Health Questions

Health Questions

Information for joint applicant

Health Questions

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