Illinois Alliance Insurance

AUTO INSURANCE QUOTE SHEET

Please fill in the information below and use the submit button to send to our office. This information is sent via a secure server to protect your privacy. If you prefer, you may print this form and mail it to the address below.

NOTE: All Fields Are Required. If you don't want to enter your Social Security Number, enter 000-00-0000 in the SS# area and we will call you for that information.

Name

SS#

Date of Birth

Driver's License#

Name

SS#

Date of Birth

Driver's License#

Name

SS#

Date of Birth

Driver's License#

Address				City, State, Zip
Daytime Phone				E-mail Address
Own Home Rent
Current Insurance
Company				Policy Number
Effective Date of Policy
Any Tickets/Accidents/Claims in last three years? Yes No				Explain
All Vehicles Titled in Your Name? Yes No
Any Vehicles Used for Delivery? Yes No

Year

Make

Model

VIN # (if available)

Principal Driver

Miles Driven to Work/School

LIMITS DESIRED

Bodily Injury (in thousands)		Other (please specify)
Property Damage (in thousands)		Other (please specify)
Medical Payments (in thousands)		Other (please specify)
Uninsured Motorist (in thousands)		Other (please specify)
Underinsured Motorist (in thousands)		Other (please specify)
Comprehensive Deductible		Other (please specify)
Collision Deductible		Other (please specify)
Towing Yes No Rental Yes No		Anyone away at school over 100 miles? Yes No
Good Student Discount (B Average) Yes No		With car? Yes No Without car? Yes No

Year

Make

Model

VIN # (if available)

Principal Driver

Miles Driven to Work/School

LIMITS DESIRED

Bodily Injury (in thousands)		Other (please specify)
Property Damage (in thousands)		Other (please specify)
Medical Payments (in thousands)		Other (please specify)
Uninsured Motorist (in thousands)		Other (please specify)
Underinsured Motorist (in thousands)		Other (please specify)
Comprehensive Deductible		Other (please specify)
Collision Deductible		Other (please specify)
Towing Yes No Rental Yes No		Anyone away at school over 100 miles? Yes No
Good Student Discount (B Average) Yes No		With car? Yes No Without car? Yes No

Year

Make

Model

VIN # (if available)

Principal Driver

Miles Driven to Work/School

LIMITS DESIRED

Bodily Injury (in thousands)		Other (please specify)
Property Damage (in thousands)		Other (please specify)
Medical Payments (in thousands)		Other (please specify)
Uninsured Motorist (in thousands)		Other (please specify)
Underinsured Motorist (in thousands)		Other (please specify)
Comprehensive Deductible		Other (please specify)
Collision Deductible		Other (please specify)
Towing Yes No Rental Yes No		Anyone away at school over 100 miles? Yes No
Good Student Discount (B Average) Yes No		With car? Yes No Without car? Yes No

Mailing Address for Form:

Justin Ramsey
Illnois Alliance Insurance
421 East Grant Hwy.
Marengo, IL 60152