Car Insurance Quotation Form

Car Insurance Quote Request
Proposed Named Insured*

First NameMiddle NameLast Name
Phone Number*
E-mail*
example@example.com
Spouse, Domestic Partner or Second Named Insured

First NameMiddle NameLast Name
Phone Number
E-mail
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is the mailing address different from residence address?*

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

HOUSEHOLD DRIVERS

Please enter all permit and licensed drivers below.
Number Of Drivers*
Driver #1:*

First NameLast Name
Driver #1: Date of Birth*

MonthDayYear
Date
Driver #1: Driver's License Number*
Driver #1: SS#
Driver #1: Occupation
Driver #2:

First NameLast Name
Driver #2: Date of Birth

MonthDayYear
Date
Driver #2: Driver's License Number
Driver #2: SS#
Driver #2: Occupation
Driver #3:

First NameMiddle NameLast Name
Driver #3: Date of Birth

MonthDayYear
Date
Driver #3: Driver's License Number
Driver #3: SS#
Driver #3: Occupation
Driver #4:

First NameMiddle NameLast Name
Driver #4 :Date of Birth

MonthDayYear
Date
Driver #4: Driver's License Number
Driver #4: SS#
Driver #4: Occupation
Driver #5:

First NameMiddle NameLast Name
Driver #5: Date of Birth

MonthDayYear
Date
Driver #5: Driver's License Number
Driver #5: SS#
Driver #5: Occupation
Driver #6:

First NameMiddle NameLast Name
Driver #6: Date of Birth

MonthDayYear
Date
Driver #6: Driver's License Number
Driver #6: SS#
Driver #6 :Occupation

Are any of the vehicles garaged at a different address? If so, please provide an explanation below.

COVERAGES

Coverages may vary by insurance carrier. Please review quote for actual coverages being offered by the insurance carrier.
Bodily Injury Liability (Injuries you cause to others)
Helps to cover medical bills, lost wages, and pain & suffering of other people injured in an accident; also helps cover your legal defense if you're sued. (Each Person / Each Accident)
Uninsured / Underinsured Motorist Coverage (If you're hit by someone who has no insurance or not enough)
Helps pay for your inuries and damages if the other driver has no insurance. Underinsured Motorist helps when the other driver's policy limits are not high nough to cover your costs. (Each Person / Each Accident)
Property Damage Liability (Damage to others' property)
Pays for damage to someone else's car or property caused by your vehicle
Medical Payments Coverage
Helps pay for medical expenses for you and your passengers
Collision Deductible
A collision deductible is the amount of money you agree to pay out of pocket when you file a claim for damage to your own vehicle caused by a collision — such as hitting another car, a pole, or a guardrail — before your insurance company pays the rest.
Comprehensive Deductible
A comprehensive deductible is the amount you pay out of pocket before your insurance covers damage to your car caused by non-collision events — things other than a crash with another vehicle or object.
Do you want any add-ons to your vehicles?

Roadside AssistanceRental Car CoverageGlass ReplacementGap CoverageCustom Equipment CoverageRideshare Coverage (Uber, Lyft, etc.)

Are you currently insured?*

YesNo
How long have you been with your current carrier?
Who is your current insurance carrier?
Requested Effective Date?

MonthDayYear
Date

Any other details you would like to share to assist us in your auto quote?

Terms and Conditions for Online Insurance Quotes
10-14-2025
Ottawa Northern Insurance Service, Ltd.
www.northerninssvc.com

1. Purpose of Quote
The information you provide through this online form will be used to prepare an insurance quote estimate. This quote is for informational purposes only and does not constitute an offer, policy, or guarantee of coverage.
Final premiums, terms, and eligibility are determined after a full underwriting review by Ottawa Northern Insurance Agency and/or its partner carriers.

2. Accuracy of Information
You agree that all details submitted are accurate and complete to the best of your knowledge. Any incorrect, incomplete, or misleading information may result in:
- An inaccurate quote
- A delay or denial in coverage, or
- The cancellation of a policy if later found to be untrue.
3. No Coverage or Policy Issuance

Submitting this quote request does not provide or bind insurance coverage.
Coverage only becomes effective after:
- A full application is completed,
- All required information and documentation are reviewed,
- The carrier approves the risk, and
- The first premium payment is received and accepted
4. Use of Personal Information

By submitting this form, you authorize Ottawa Northern Insurance Agency to collect and use your information for the purpose of generating insurance quotes and communicating about insurance options. Your information will remain confidential and used only as permitted under applicable privacy laws.

5. Electronic Communication Consent
By providing your contact details, you consent to receive communications from Ottawa Northern Insurance Agency by phone, email, or text message regarding your insurance inquiry or related services. Message and data rates may apply. You may opt out at any time.

6. Partner Carriers
Ottawa Northern Insurance Agency works with multiple licensed insurance carriers to provide coverage for auto, home, commercial, life, and health insurance. Quotes may be based on preliminary information from one or more partner carriers, each of which maintains its own underwriting rules and policy terms.

7. Limitation of Liability
Ottawa Northern Insurance Agency is not liable for any damages or losses that may arise from the use of this website, quote form, or reliance on any preliminary quote provided. All quotes are estimates and subject to change upon full underwriting review.

8. Changes to Terms
These Terms and Conditions may be updated at any time without prior notice. The revised version will be posted here with an updated effective date.

9. Contact Information
If you have any questions regarding these Terms and Conditions, please contact:
Ottawa Northern Insurance Agency
605 Clinton Avenue Ottawa, Il 61350
Phone: 815-433-0560
Email: rfouth@northernins.com Website: www.northerninssvc.com
I have read and understand the terms and conditions.*

YesNo
Should be Empty:

Car Insurance Quote Request

HOUSEHOLD DRIVERS

VEHICLES

COVERAGES