Auto Quote Form

Auto Insurance Info Request 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
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred method of contact (phone, email, text, other)
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Marital Status
How did you hear about Langlois Insurance Agency?
If you were referred by a current customer, please let us know their name so we know who to thank!
Do you currently have Auto Insurance?
Is your current Auto Insurance policy active?
List Drivers
List Vehicles
What type of coverage are you looking for for your Auto Insurance? (check all that apply)
Please upload a copy of your current Auto Insurance policy

Cancelof
Have any drivers in the household had any accidents in the last 7 years?
If YES, to above, please provide the date of accident, driver involved, and a brief description:
Have any drivers in the household had any tickets or violations in the last 7 years?
If YES, to above, please provide the date of ticket/violation, the type of ticket/violation, and the driver involved:
Any DUI, suspended license, or major violations?
Does anyone in the household drive for Uber, Lyft, or similar type company?
Are you interested in bundling other policies (please check all that apply):
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.”
Should be Empty:

Auto Insurance Info Request Form