AUTO INSURANCE QUOTE SHEET

Please fill in the information below and use the submit button to send to our office. This information is sent via a secure server to protect your privacy. If you prefer, you may print this form and mail it to the address below.

NOTE: All Fields Are Required. If you don't want to enter your Social Security Number, enter 000-00-0000 in the SS# area and we will call you for that information.
 

  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:

Glenn Jensen
Illnois Alliance Insurance
7227 W. 127th Street
Palos Heights, IL 60463