217-355-5555
 


 

 

Additional Information

About Us
Contact Us

 
AUTO
insurance		 HOME & PROPERTY
 insurance		 BUSINESS & COMMERCIAL
insurance		 LIFE
insurance		 MEDICAL
insurance

Quick Auto Insurance Quote Form

Telephone: 217-355-5555

Fax: 217-355-6768

Physical Address:
2002 South Neil Street; Champaign, IL 61821

Mailing Address:
P.O. Box 3398; Champaign, Il. 61826-3398

Electronic Mail:
use our quick contact form.

 

1) Please tell us about yourself

First Name
Last Name
Address
City
State
Zip Code
Email
Home Phone
Work Phone
Fax
Occupation

  I currently receive an auto and home/renters discount.
 A driver on my policy currently qualifies for a "good student" discount. (B or better

     grade average.)

2) Current Carrier Information

What is the expiration date of your current policy?

Date 

Who is your current auto insurance carrier (not agency)?

What is your current premium?

What length is your policy term?

3) Vehicle Information

List the vehicles currently insured or vehicles you want insured.

Vehicle One

Year Make Model Use

Safety Devices?

Vehicle Identification Number for vehicle one.

Vehicle Two

Year Make Model Use

Safety devices?

Vehicle Identification Number for vehicle two.

Vehicle Three

Year Make Model Use

Safety devices?

Vehicle Identification number for vehicle three.

Vehicle Four

Year Make Model Use

Safety devices?

Vehicle Identification number for vehicle four.

 

4) Coverage Information

Select the coverage you desire for each vehicle to be insured.
  Bodily Injury and Property Damage Liability Limits. Under and Uninsured Limits will match your choice. Medical Payments Comprehensive Deductible Collision Deductible
Vehicle One
Vehicle Two Same as above.
Vehicle Three Same as above.
Vehicle Four Same as above.

Do you want towing and labor coverage? (Available only if vehicle has comprehensive coverage.)

Do you want rental reimbursement coverage?

5) Driver Information

Who are the drivers in your household?

Name Date of Birth Sex Marital Status

6) Accidents and Violations

In the past 5 years have any of the above drivers had any accidents or violations?  

Note: you will only be charged with those that are within the last 3 years.

If yes, please list.

Name Date Type

Please use this area for any comments you may have.

7) How would you would you like us to reply?

E-Mail, US Mail , Home Phone , Work Phone , FAX , ANY

Note: This will NOT bind coverage.
You must apply in person to obtain coverage.

Thank you for your request!

For a homeowners or renters insurance quote click here!