Personal Auto Quote Form
Agent Information
Quote Urgency:  (Req'd)
Producing Agency:      
Producer's Name:      
Producer's Phone:      
Return Quote via: Email Fax  
               
 

Applicant / Titleholder
 Name:  Term: 6 Months     12 Months
Address:  Effective Date:
City: Phone:   
State: County:
Zip:    
Does the applicant own their home or rent?  

 
Current Insurance
Does the applicant have insurance currently?    Yes     No
If YES, please complete the following:
Company Name: Expiration Date:
Number of continuous months with them:        
       
Where there any losses in the last 3 years?    Yes     No
When was the last loss by the applicant?  

The companies require that ALL members of the household (over the age of 14) be disclosed.  These people must either be added to the policy (and rated) or excluded from the policy.  Please fill out the following sections accordingly.
Drivers - ALL people in household over 14 must be listed, either as a driver or in the excluded driver section in red below.
Required Info Driver 1 Driver 2 Driver 3 Driver 4
Name:
Date of Birth:
Sex / Martial Sts:
Relation:
Driver's Lic #:
Months Licensed:
Miles to Work:
Occupation:
SR-22: SR-22 Needed SR-22 Needed SR-22 Needed SR-22 Needed
Driving Record:
(last 3 years)
Do any operators have a suspended, revoked, expired or cancelled license?   Yes     No  If yes, please list driver and explain below in the comments section at the end.
Enter violations for each driver for the past 3 years.  If more than 3 exist, enter in Notes/Comments.
 1 Date:
Description:
2 Date:
Description:
3 Date:
Description:
Notes/Comments:
More drivers?        
Notes:        
If more than 4 drivers are required, we will contact you for the additional information.
Excluded Drivers - No coverage when vehicles are operated by the people below.
Required Info Excluded 1 Excluded  2 Excluded  3 Excluded  4
Name:
Date of Birth:
Sex / Martial Sts:
Relation:
More exclusions?        
Notes:        
If more than 4 excluded drivers are required, we will contact you for the additional information.


Vehicles
Required Info Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Year:
Make:
Model:
VIN#'s are not required to quote but are required to bind the policy.
They are also helpful on Physical Damage quotes to be more accurate.
If not available, please describe specific model as much as possible, i.e. LX, GTS, etc...
VIN #:
Roof Feature:
Conversion Van? Conversion Van Conversion Van Conversion Van Conversion Van
Leased Vehicle? Leased Vehicle Leased Vehicle Leased Vehicle Leased Vehicle
Primary Driver:
More vehicles?      
Notes:        
If more than 4 vehicles are required, we will contact you for the additional information.

Coverages - Liability
Required Info Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Bodily Injury:
Property Damage:
Medical Payments:
Uninsured Motorist:
Underins Motorist:
UM Property Damge:
*minimum required limits in Illinois

Coverages - Physical Damage
Required Info Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Collision Deductible:
Comprehensive Ded:
Towing and Rental coverages vary by company.  Review application for exact amount.
Towing Reimburmnt:
Rental Reimburmnt:

General Underwriting Questions/Comments/Submission
1. Do any operators drive for Uber, Lyft or similiar services?    Yes     No
2. Do any operators use their vehicle for commerical, business or artisian use?     Yes  No 
     If yes, please explain below in the comments section.

3. Do any operators have any physical or mental impairment including but not limited to alcoholism,             epilepsy, fainting spells, neurological disorders, stroke, diabetes, loss of vision, seizures, blackouts, heart/circulatory disorders, cerebral palsy or loss of limb unless compensated by vehicle or use any medication which may affect their driving ability?    Yes     No    If yes, please list driver and explain below in the comments section.

4. Has any vehicle been altered, modified or customized?    Yes     No   If yes, please explain below in the comments section.
Additional Comments:

 
If you wish to have a copy of this submission for your records, you must print page BEFORE submitting.  Note: the radio buttons and check boxes will not print.


If you wish to have a copy of this submission for your records, you must print page BEFORE submitting.




Please note - There might be a delay upon submission.
Do not exit until you receive the "Confirmation Page."
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