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Customer Service: 773.774.9404
ILLINOIS VEHICLE
®
Personal Information
Full Name:
Phone Number:
Best time to be reached:
Anytime
Mornings
Afternoons
Evenings
Gender:
Male
Female
Marital Status:
Single
Married
Birth Date:
Zip Code:
E-mail:
Vehicle One
Year:
Make:
Model:
Vehicle Two
Year:
Make:
Model:
Have you been Licensed for at least 3 years:
Yes
No
Licence Type:
Valid
Permit
Out of State
International
SR22 Required?:
Yes
No
Last Violation Date (dd/mm/yyyy):
Violation Type:
None
All Accidents at Fault
All Accidents not at Fault
All Other 6 205 and 6 206 Violations not listed
Careless Driving
Child Safety Seat Unrestrained Child
Currently Revoked or Cancelled License
Defective brakes
Disregarding stop or yield sign at an intersection
Drag Racing on Public Streets
Driving During Suspension
Driving under the influence of Drugs or Alcohol
Driving Without Insurance
Expired Drivers License
Failure to Appear
Failure to Stop at RailRoad
Failure to Yield
Failure to Yield to a Pedestrian or EMS
Felony Involving the use of a Vehicle
Fleeing, Attempting to Elude or Failing to Stop
Following too closely
Head, tail or side light violation
Hit and Run
Illegal Transportation of Alcohol
Implied Consent
Improper Passing
Lane Violation
Leaving the Scene of an Accident Involving BI or
Lending Drivers license
Missing License or Unverifiable License
Open Container Violation
Other Major
Other Minor
Passing Stopped School Bus
Permiting Unlicensed Driver to Drive
Reckless Homicide, Manslaughter or Assault
Reckless or Negligent Driving
Refusing or Failing Sobriety Test
Seat Belt Violation
Speeding over 25
Speeding too fast for conditions
Speeding under 25
Statutory Summary Suspension
Suspension all other
Suspension for Failure to Appear
Policy Term:
6 Month
12 Month
Bodily Injury Coverage:
$20,000/$40,000
$25,000/$50,000
$50,000/$100,000
$250,000/$500,000
Property Damage Coverage:
$15,000
$25,000
$50,000
Uninsured Motorist/Under Insured Motorist:
$20,000/$40,000
$25,000/$50,000
$50,000/$100,000
$250,000/$500,000
Medical Payments:
Optional
$500
$1,000
$2,000
$5,000
Uninsured Motorist Physical Damage:
Optional
$15,000
Comprehensive / Collision:
Optional
$250
$500
$1000
Rental:
Optional
$20 per day
$30 per day
Towing:
Optional
$25 Per Disablement
$50 Per Disablement
For Immediate Quotes/Coverage
Call Toll Free
1 877.778.7888
