New Client Quote Request
Please fill the form accurately for better assistance OR call 217-546-5546
How did you hear about us? Were you referred by anyone?
Please Select
Website
Google
Referral
What is the name of the person who referred you? We would like to send them a quick thank you.
Lines of business to be quoted:
*
Home
Condo
Renters
Auto
Umbrella
Valuable Articles
Rec Vehicle / Motorcycle
Boat
Motorhome
Other
When do you need this quote returned by?
*
-
Month
-
Day
Year
Date
Customer Info
Primary Insured Name
*
First Name
Last Name
Primary Insured Date of Birth:
*
-
Month
-
Day
Year
Date
Relationship Status
*
Married
Single
Widowed
Divorced
Other
Spouse Name
*
First Name
Last Name
Spouse Date of Birth:
*
-
Month
-
Day
Year
Date
Primary E-mail
*
example@example.com
Primary Insured Cell
*
Do you give permission to text this number:
*
Yes
No
Primary Insured Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is current insurance active?
*
Yes
No
Other
Name of Current Carrier
Current Premium to Beat:
When does your current insurance expire?
*
-
Month
-
Day
Year
Date
Set appointment for quote review?
Yes
No
Umbrella Coverage
Limit Requested
*
Please Select
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Do you want UM/UIM coverage?
*
Yes
No
Any international travel planned?
*
Yes
No
Valuable Articles
Valuable Articles List
Rows
Amount
Description
Appraisal Attached
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Desired Ded.
Attach Appraisal(s)
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Watercraft
Watercraft Info
*
Rows
Year / Make / Model
Hull Number
Motor Yr/Make
Max Speed
HP or CC
Trailer amount
Watercraft 1
Watercraft 2
Watercraft 3
Watercraft 4
Rec Vehicle / Motorcycle
Rec Vehicle / Motorcycle Driver Info
*
Rows
Name / Relationship
DOB
Drivers License
Social
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Driver 6
Rec Vehicle / Motorcycle Info
*
Rows
Year/Make/Model
Serial Number
Value
CC / HP
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Rec Vehicle / Motorcycle Liability Limits
Rows
Limits Requested
Liability Limits - Suggested 250/500
Property Damage - Suggested 100
Medical - $10,000
UM - Suggested 250/500
UIM - Suggested 250/500
Comp Ded - Suggested $1,000
Coll Ded - Suggested $1,000
Other Not Listed - Document Coverage needed
Do any of the Rec Vehicle / Motorcycle have a loan or lease
*
Yes
No
List the vehicle number - Name / Address - Loan or Reference Number
Auto Questions
Auto Driver Info
*
Rows
Name / Relationship
DOB
Drivers License
Social
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Driver 6
Vehicle Info
*
Rows
Year/Make/Model
Vin
Deductible
Usage
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Do any of the Vehicles have a loan or lease
*
Yes
No
List the vehicle number - Name / Address - Loan or Reference Number
Ticket or Accidents last 3 years?
*
Yes
No
List any tickets or accidents in the last 3 years:
Do you use any of these vehicles in the course of business?
*
Yes
No
List Vehicle Number - How is this vehicle used in the course of business?
Preferred Vehicle Liability Limits
Rows
Limits Requested
Liability Limits - Suggested 250,000/500,000
Property Damage - Suggested minimum 100,000
Road Side - include or exclude
Medical - $10,000
UM - Suggested 250,000/500,00
UIM - Suggested 250,000/500,000
Comp Ded - Suggested $1,000
Glass - include or exclude
Coll Ded - Suggested $1,000
Telematics - Included, can remove after review
OEM Coverage -
Other Not Listed - Document Coverage needed
Available discounts
Good Student
Low Milage
Occupation Discount
Other
Supporting discount documents:
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Condo Quote
Coverage Options
Rows
Limits Requested
Personal Property Coverage
Structure Coverage
Water/Sewer - Included, $25,000
Personal Injury - Included, can remove after review
ID Theft - Included, can remove after review
Policy Deductible
Loss Assessment Coverage Amount
Renters Questions
Coverage Options
Rows
Limits Requested
Personal Property Coverage
Water/Sewer - Included, $25,000
Personal Injury - Included, can remove after review
ID Theft - Included, can remove after review
Policy Deductible
Home Questions
Home details
Rows
Home Details
Year Built
Construction Type (Brick, Frame, Stucco...)
Roof Material
Total square footage (excluding basement)
# of Stories
# of Bathrooms
Foundation Type & Percent Finished
Garage (# of Bays / Attached or Detached)
Trampoline or Pool & is it fenced
Fireplace or Chimney
Updates to property
Rows
Limits Requested
Roorf year
Plumbing Year & Full or Partial
Electrical Year & Full or Partial
HVAC Year & Full or Partial
Coverage Options
Rows
Limits Requested
Earthquake
Water/Sewer - Included, $25,000
Personal Injury - Included, can remove after review
ID Theft - Included, can remove after review
Flood
Mine Subsidence/Sink Hole
Work Comp
Valuable Articles - Included, can remove after review
Service Line Coverage
Sinkhole Coverage
Dog or Exotic Pet on premise
*
Yes
No
Any known bite history?
*
Yes
No
Provide pet details here, breed or type of pet:
If unknown please use customers best guess
Are you aware of any claims in the last 3 years?
*
Yes
No
List claims details below:
Is their a mortgage on the home?
*
Yes
No
Name of Bank or Institution - Address - Loan #
Is this home in a Trust or LLC?
*
Yes
No
List the Trust or LLC as it should be listed (*Carrier may request copies of titles if you have them attached at bottom of submission)
Attachments & Notes
Attachments to save to the account:
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Notes on the account:
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