Illinois Alliance Insurance

AUTO INSURANCE QUOTE SHEET

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NOTE: All Fields Are Required.

Name

SS#

Date of Birth

Driver's License#

Name

SS#

Date of Birth

Driver's License#

Name

SS#

Date of Birth

Driver's License#

Address				City, State, Zip
Daytime Phone				E-mail Address
Own Home Rent
Current Insurance
Company				Policy Number
Effective Date of Policy
Any Tickets/Accidents/Claims in last three years? Yes No				Explain
All Vehicles Titled in Your Name? Yes No
Any Vehicles Used for Delivery? Yes No

Year

Make

Model

VIN # (if available)

Principal Driver

Miles Driven to Work/School

LIMITS DESIRED

Bodily Injury (in thousands)		Other (please specify)
Property Damage (in thousands)		Other (please specify)
Medical Payments (in thousands)		Other (please specify)
Uninsured Motorist (in thousands)		Other (please specify)
Underinsured Motorist (in thousands)		Other (please specify)
Comprehensive Deductible		Other (please specify)
Collision Deductible		Other (please specify)
Towing Yes No Rental Yes No		Anyone away at school over 100 miles? Yes No
Good Student Discount (B Average) Yes No		With car? Yes No Without car? Yes No

Year

Make

Model

VIN # (if available)

Principal Driver

Miles Driven to Work/School

LIMITS DESIRED

Bodily Injury (in thousands)		Other (please specify)
Property Damage (in thousands)		Other (please specify)
Medical Payments (in thousands)		Other (please specify)
Uninsured Motorist (in thousands)		Other (please specify)
Underinsured Motorist (in thousands)		Other (please specify)
Comprehensive Deductible		Other (please specify)
Collision Deductible		Other (please specify)
Towing Yes No Rental Yes No		Anyone away at school over 100 miles? Yes No
Good Student Discount (B Average) Yes No		With car? Yes No Without car? Yes No

Year

Make

Model

VIN # (if available)

Principal Driver

Miles Driven to Work/School

LIMITS DESIRED

Bodily Injury (in thousands)		Other (please specify)
Property Damage (in thousands)		Other (please specify)
Medical Payments (in thousands)		Other (please specify)
Uninsured Motorist (in thousands)		Other (please specify)
Underinsured Motorist (in thousands)		Other (please specify)
Comprehensive Deductible		Other (please specify)
Collision Deductible		Other (please specify)
Towing Yes No Rental Yes No		Anyone away at school over 100 miles? Yes No
Good Student Discount (B Average) Yes No		With car? Yes No Without car? Yes No

Mailing Address for Form:

Kathy Backhaus
Illnois Alliance Insurance
4915 W. Elm Street, Suite C
McHenry, IL 60050