EQUITY INSURANCE AGENCY

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630-627-7764

Auto Insurance Request

* Required Fields

	Name:*
	Address:
	City:*
	State:*	Zip:*
	Home Phone:
	Bus. Tel:
	E-Mail:*
	Are you currently insured? Yes No
	Do you have a current renewal notice? Yes No
	Liability Coverages* (select one per category, amounts in thousands)
	* Bodily Injury 20/40 25/50 50/100 100/300 250/500
	* Property Damage 15 25 50 100 250
	* Medical Payments 1 5 10 25 50
	* Do you currently: Own Rent
	Driver's Information List all drivers in the household.
No.	Driver Name*	Date of Birth* (Mo/Day/Year)	Married?*	Violations/ Accidents* (In last 3 years)	Good Student ("B" or better)	At School?
1*			Y N	Y N	Y N	Y N
2			Y N	Y N	Y N	Y N
3			Y N	Y N	Y N	Y N
4			Y N	Y N	Y N	Y N
	Vehicle Information (Please follow order of drivers listed above.)
No.	Model Year*	Make*	Model*	Sub-Model (LS, GT, XE)	Is vehicle used to work, school or train?	Miles One Way
1*					Y N
2					Y N
3					Y N
4					Y N
	Optional Coverages (Please follow order of vehicles listed above.)
No.	Comprehensive	Deductible	Collision	Deductible	Towing	Rental
1	Y N		Y N		Y N	Y N
2	Y N		Y N		Y N	Y N
3	Y N		Y N		Y N	Y N
4	Y N		Y N		Y N	Y N
	List all traffic convictions/accidents/claims in the last 3 years:
No.	Driver Name	Month and Year	Description
1
2
3
	Additional comments that may effect outcome of request:

	if you would like to talk to a representative regarding any questions on this questionnaire, or an insurance request for something other then you see on our web site, call our toll-free direct line at 877-627-7808 and we can take your insurance information directly over the phone.
	Equity Insurance Agency works directly with independent insurance carriers to get you the best rates with "A"-rated companies with excellent claims and customer service.