Automobile Insurance Quote Form
For the fastest and most accurate automobile insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!
Please fill in the blanks using your computer, then print (press Control-P or Print from the File menu)
and fax this form to:
Highland: 618.654.3826 or Greenville: 618.664.1858 or
Edwardsville: 618.656.8528.
Thanks from SIUA, Inc. Back to previous page here.

General Information
Name:
Address:
City:   State: ZIP:
County:   Email:
Phone Day: ( ) -            Night: ( ) -
Best time to call:   AM   PM            YOUR Social Security #: --

Current Auto Insurance Company (not agency):
Company Name:
Policy Exp. Date: / /
Premium: $
Term: 6 Months   1 Year   Other  

Vehicle Information:
(include all cars you or your family members own or lease)
Car #1 Year Make Model Sub Model Body Type Vehicle ID# (VIN)  
19  
Name of Title Holder
 Annual Mileage
 Drive to school, work, station? Yes   No
# of miles (one way): 		Car equipped w/ airbags? Yes   No
Anti-theft devices?
Yes   No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:
What are your current Limits of Liability (on this vehicle)?
What is your current Comprehensive Deductible (on this vehicle)?
What is your current Collision Deductible (on this vehicle)?
Do you have Towing and Labor coverage? Yes   No

Car #2 Year Make Model Sub Model Body Type Vehicle ID# (VIN)  
19  
Name of Title Holder
 Annual Mileage
 Drive to school, work, station? Yes   No
# of miles (one way): 		Car equipped w/ airbags? Yes   No
Anti-theft devices?
Yes   No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:
What are your current Limits of Liability (on this vehicle)?
What is your current Comprehensive Deductible (on this vehicle)?
What is your current Collision Deductible (on this vehicle)?
Do you have Towing and Labor coverage? Yes   No

Car #3 Year Make Model Sub Model Body Type Vehicle ID# (VIN)  
19  
Name of Title Holder
 Annual Mileage
 Drive to school, work, station? Yes   No
# of miles (one way): 		Car equipped w/ airbags? Yes   No
Anti-theft devices?
Yes   No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:
What are your current Limits of Liability (on this vehicle)?
What is your current Comprehensive Deductible (on this vehicle)?
What is your current Collision Deductible (on this vehicle)?
Do you have Towing and Labor coverage? Yes   No

Driver Information:
(including all licensed drivers in your household)
Driver's Name Occupation Relation
to you		 Date of birth
(Mo/Day/Yr)

Male/
Female

M / F

Married/
Single

M / S

 Completed # of Yrs.
Licensed		 % of Vehicle Use
Drivers
Education
Course		 Accident
Prevention
Course		 #1 #2 #3
Self M
F		 M
S		 Y
N		 Y
N
M
F		 M
S		 Y
N		 Y
N
M
F		 M
S		 Y
N		 Y
N
M
F		 M
S		 Y
N		 Y
N
Driving Percentage Total Must Add Up To:   100% 100% 100%

Driver History

If you answer "yes" to any of the following questions below,
please explain in the space provided:

Has any driver listed:
1. Been convicted of any moving traffic violation in the past 3 years?
    Yes   No
    If yes, please answer the following:
Driver Date Type of Conviction Time Fines Speed
Over Limit
// $ MPH
// $ MPH
// $ MPH
// $ MPH

2. Had his or her license suspended or revoked (ever)?
    Answer only if "yes":
Driver Suspended Revoked
Yes Yes
Yes Yes
Yes Yes
Yes Yes

3. Been convicted of driving under the influence of alcohol or drugs?
    Answer only if "yes":
Driver Alcohol Drugs
Yes Yes
Yes Yes
Yes Yes
Yes Yes

4. Been involved in any accidents, regardless of fault, in the past 5 years?
    Yes   No
    If yes, please answer the following:
Driver Date Cost Fines Injuries At Fault Time Description
// $ $ Y
N		 Y
N
// $ $ Y
N		 Y
N
// $ $ Y
N		 Y
N
// $ $ Y
N		 Y
N

Additional Comments:
Please give any additional comments about the coverage you desire:

Thank you for your time in submitting this automobile quote form. One of our representatives will respond to your submission as soon as possible!


Back to the SIUA, Home Page.