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On-Line Antique, Classic &
Collector's Car Insurance Quote
One Simple Form - takes only 2-3 Minutes!
Your Personal Data

Your Name:
Street Address:
City:
Your "County" is?
State: (Must be Illinois)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)

DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:

DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:

VEHICLE #1 INFORMATION
Year of vehicle: Make & Model:
Value of vehicle: Additions or Alterations:
Annual Mileage: How Often is Vehicle Used & for What Purposes?
Where is Vehicle Kept, Describe locked garage?: Vehicle Originally equipped? (describe modifications)
VEHICLE #1 COVERAGES:
Limits of
Liability:		 $30/60 BI / 25 PD $50/100 BI / 50 PD
$100/300 BI / 50 PD $250/500 BI / 100 PD
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?		 Yes No   Uninsured
  Motorists Cov.?		 Yes No
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Value of vehicle: Additions or Alterations:
Annual Mileage: How Often is Vehicle Used & for What Purposes?
Where is Vehicle Kept, Describe locked garage?: Vehicle Originally equipped? (describe modifications)
VEHICLE #2 COVERAGES:
Limits of
Liability:		 $30/60 BI / 25 PD $50/100 BI / 50 PD
$100/300 BI / 50 PD $250/500 BI / 100 PD
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?		 Yes No   Uninsured
  Motorists Cov.?		 Yes No
Comments or Remarks:
(List additional drivers, autos, etc. here)

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© 2005, Roth and Roth Insurnace Agency . 2424 W. Indian Trail - F . Aurora, IL . 60506
Toll Free Phone: 800 416-9196 . Phone: 630-907-0611 . Fax: 630-907-0667
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