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Automobile Insurance Quote

Are You Frustrated with Agents Misquoting Rates and then Raising the Rate at Time of Sale?
*Providing the required information below will result in more accurate initial quotes.
 

Personal Information

First Name:*  
Middle Initial:  
Last Name:*  
Street Address:*  
Floor/Suite Number:  
City:*  
State:*  
Zip Code:*  
Email Address:*  
Phone Number:*  
(Enter 10 digits only)
Fax Number:  
(Enter 10 digits only)

Please Answer the Questions Below

Named Insured licensed driver more than five (5) years?*   Yes No
 
All drivers held valid US license for past 12 months (excluding new drivers under 18)?*   Yes No
 
One (1) major violation or more than five (5) incidents per policy in last five (5) years?*   Yes No
 
One (1) major violation or more than four (4) incidents per driver in last five (5) years?*   Yes No
 
Theft losses in last three (3) years?*  
 
More than three (3) comprehensive towing claims in last five (5) years, with more than $1,000 total paid out?*   Yes No
 
Do you wish to insure any of the following: AC all, Acura NSX, Aston Martin, Avanti, Bentley, Bricklin, Cobra, DeLorean, DeTomasso, Dodge Viper, Excalibur, Ferrari, Hummer, Jenson Interceptor, Lamborghini, Lancia Scorpion, Lotus, Maserati, Morton, Panoz, Pantera, Pininfarina, Plymouth Prowler, Quavale, Rolls Royce, Subaru Brat, Suzuki Samauri or Sidekick, TVR, Vector, Yugo or any exotic cars, kit cars, vehicles modified for performance or racing, any customized vehicle or vehicle changed to be one-of-a-kind, any vehicle with modified suspension, any replica model, any vehicle with a plastic/aluminum/stainless steel body, or any ATV/dune buggies/vehicles used for off-road?*   Yes No
 
Select the Named Insured's credit score:*  
 
Garaging address residence type:*  
 
Been at current address less than six (6) months?*   Yes No

Driver1 Information

First Name:*
Middle Init:
Last Name:*  
Date of Birth:* Choose Date
Gender:*
The next three fields are required for an accurate quote. If not given here, you will be contacted to get them.
Social Security Number:
DL Number:
Licensing State:
Marital Status:*
Driver Relationship:*
Single parent with full-time child custody?*
(Note: Rate-bearing question.) 		 Yes  No
Driver's Industry:*
Driver's Occupation:*
Education level:*
(Note: Rate-bearing question.)
Date licensed if less than four(4) years: Choose Date
Driver Discounts and Surcharges
Age when first licensed?*
Driver's license suspended or revoked in last five(5) years?*  Yes  No
Driver training?  Yes  No
Classify as a "Good Student Driver"? (Note: Proof must be provided prior to binding.)  Yes  No
Reside at school more than 100 miles from garaging location?  Yes  No
Defensive Driver course date: Choose Date
SR-22 (Financial Responsibility) Filings:*

Driver Comments

If you have more than three drivers or need to leave other information, please use this comment box.
Comments or Remarks
(List additional driver information here)		  

Vehicle1 Information

Year:*
Make:*
Model:*
Vehicle Identification Number (VIN):*
Primary use:*
Annual miles driven:*
Number of days per week driven (to work or school or carpool):*
Number of weeks per month driven (to work or school or carpool):*
One-way mileage for vehicle's primary use (e.g., work, school):*
Approximate odometer reading:*
Date of odometer reading:* Choose Date
Vehicle purchased new?*  Yes  No
Is garaging address different from mailing address?*  Yes  No
Primary driver for this vehicle:*
Percentage of time primary driver drives this vehicle:* %
Secondary driver for this vehicle:
Percentage of time secondary driver drives this vehicle: %
Comprehensive deductible:*
Any additional comprehensive coverage deductibles to be quoted:
Special Equipment description, if coverage desired:
Tapes/Records/Discs coverage?*
Collision deductible:*
Any additional collision coverage deductibles to be quoted:
Air bag type:*
Replacement Value coverage?
(Note: Coverage only available for vehicles not previously titled.)* 		 Yes  No
Anti-Theft system type:*
Antilock brakes?*  Yes  No
Is the Vehicle financed or leased?*  Yes  No
Loan/Lease - Comprehensive coverage?
(Note: Coverage only available for new vehicles not previously titled.)
Loan/Lease - Collision coverage?
(Note: Coverage only available for new vehicles not previously titled.)
Leasing company name, address, phone number, loan/lease number, if applicable:
Provide any additional information about this vehicle that would be of assistance during the underwriting process:

Vehicle Comments

If you have more than four vehicles or need to leave other information, please use this comment box.
Comments or Remarks
(List additional vehicle information here)		  

Prior Insurance Information

Current Personal Automobile Policy?*   Yes No
Any Personal Automobile claims/incidents in last five (5) years?*   Yes No

Coverages

Combined Single Limit?*   Yes No
Medical Expense Benefit coverage?*   Yes No
Uninsured Motorist (Bodily Injury) coverage?*   Yes No
Uninsured Motorist (Property Damage) coverage?*   Yes No
Excess Liability coverage?*   Yes No
Loss of Use coverage?*   Yes No
Named Non-Owner coverage?*   Yes No
Emergency Assistance coverage?*   Yes No
Towing/Labor coverage?*   Yes No
Send My Quote via:
 
 

Contact us:

1913 S. Illinois St.
Belleville, IL 62220
Phone: 618-236-1500
  618-281-1700
Fax: 618-236-1501
Email: info@NowakInsurance.com
 
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