"Quick Quote" Form
For over 40 years, Langlois Insurance Agency has helped families protect what matters most. Complete the form below and one of our licensed agents will review your information and shop for the best coverage options available.
📞 Questions? Call us at #815-485-2106 🕘 Monday–Friday | 8:00 AM– 4:30 PM
Contact Name
*
First Name
Last Name
Business Name / DBA:
Business Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Main Email
*
example@example.com
Preferred method of contact (phone, email, text, other)
Business Website, if applicable:
Years in Business:
Business Structure
Sole Proprieter
LLC
Corporation
Partnership
Other
Description of Operations:
Number of Employees:
Annual Gross Revenue:
Estimated Annual Payroll:
Current Insurance Dec Pages:
Browse Files
Drag and drop files here
Choose a file
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of
Current Insurance Carrier:
Current Premium:
Current Policy Expiration Date:
-
Month
-
Day
Year
Date
Any Claims In the Past 3-5 years?
Yes
No
Uncertain
Reason for Shopping for Insurance (check all that apply):
Price
Coverage Concerns
Service
Carrier Non-Renewal
New Business
Other
How did you hear about Langlois Insurance Agency?
Google
ChatGPT
Referral
Facebook
Current Customer
Other
If you were referred by a current customer, please let us know their name so we know who to thank!
Other than Business Insurance, what else are you insterested in getting a quote for? (please check all that apply):
Life Insurance
Business Insurance
Motorcycle Insurance
Boat Insurance
Umbrella Insurance
Renter's Insurance
Other
I understand that submitting this form does not bind coverage. A licensed representative from Langlois Insurance Agency will contact me to review coverage options and finalize any policy."
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