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400 West Main Street
Post Office Box 437
Havana, Illinois 62644-0437

Phone:
(309) 543-6631
(800) 331-0546

Fax:
(309) 543-6607

Debra Webber


Office Hours:
8 a.m. - 5 p.m. (Mon. - Fri.)







A History of the Agency

Auto Quote

No coverage is bound until you are contacted by one of our representatives

 Name  
 Street Address  
 Mailing Address  
 City, State, Zip  
 Phone Number   Home    Work 
 Email     
 Do you have insurance on your vehicle(s) now?  
 If no, when did your last policy expire?  
 If yes, what company?  
 If yes, what are your current liability limits?  
 Current Insurance
 a.   Start Date  
 b.   Expiration Date  
 Driver Information
1
 Name  
 Social Security Number  
 Drivers License Number / State    
 How long licensed?  
 Date of Birth  
 Marital Status  
List all citation received in past three years. (Including parking, seat belt, defective equipment and other non-moving citations) Include if any driver has had his/her driver's license suspended or revoked, or any major violations during the past 5 years.  
 List all accidents that were your fault
 in past three years.		  
 List all accident that were NOT your fault
 in past three years.		  
2
 Name  
 Social Security Number  
 Drivers License Number / State    
 How long licensed?  
 Date of Birth  
 Marital Status  
List all citation received in past three years. (Including parking, seat belt, defective equipment and other non-moving citations) Include if any driver has had his/her driver's license suspended or revoked, or any major violations during the past 5 years.  
 List all accidents that were your fault
 in past three years.		  
 List all accident that were NOT your fault
 in past three years.		  
3
 Name  
 Social Security Number  
 Drivers License Number / State    
 How long licensed?  
 Date of Birth  
 Marital Status  
List all citation received in past three years. (Including parking, seat belt, defective equipment and other non-moving citations) Include if any driver has had his/her driver's license suspended or revoked, or any major violations during the past 5 years.  
 List all accidents that were your fault
 in past three years.
 
 List all accident that were NOT your fault
 in past three years.		  
4
 Name  
 Social Security Number  
 Drivers License Number / State    
 How long licensed?  
 Date of Birth  
 Marital Status  
List all citation received in past three years. (Including parking, seat belt, defective equipment and other non-moving citations) Include if any driver has had his/her driver's license suspended or revoked, or any major violations during the past 5 years.  
 List all accidents that were your fault
 in past three years.		  
 List all accident that were NOT your fault
 in past three years.		  
 Vehicle Information
 ( for vehicles with a lien holder, use forms 2, 3, and/or 4 below )
1
 Year, Make, Model  Year Make Model
 Primary driver  
 Vehicle ID Number  
 Body style  
 How is vehicle primarily used?  
 If Business, describe type of business  
 If Commute, how many miles one way?
 Select coverage and limits below
 Liability        
 Un(der)insured Motorist   Will Match Liability Selection
 Medical  
 Personal Injury Protection  
 Comprehensive  
 Collision  
 Towing  Company Will Provide Limits
 Rental Reimbursement  Company Will Provide Limits
2
 Year, Make, Model  Year Make Model
 Primary driver  
 Vehicle ID Number  
 Body style  
 How is vehicle primarily used  
 If Business, describe type of business  
 If Commute, how many miles one way?  
 Lien holder
 Name  
 Address  
 Phone #  
 Fax #  
 Loan #  
 Select coverage and limits below
 Liability      
 Un(der)insured Motorist   Will Match Liability Selection
 Medical  
 Personal Injury Protection  
 Comprehensive     
 Collision               
 Towing  Company Will Provide Limits
 Rental Reimbursement  Company Will Provide Limits
3
 Year, Make, Model  Year Make Model
 Primary driver  
 Vehicle ID Number  
 Body style  
 How is vehicle primarily used?  
 If Business, describe type of business  
 If Commute, how many miles one way?  
 Lien holder
 Name  
 Address  
 Phone #  
 Fax #  
 Loan #  
 Select coverage and limits below
 Liability      
 Un(der)insured Motorist   Will Match Liability Selection
 Medical  
 Personal Injury Protection  
 Comprehensive     
 Collision               
 Towing  Company Will Provide Limits
 Rental Reimbursement  Company Will Provide Limits
4
 Year, Make, Model  Year Make Model
 Primary driver  
 Vehicle ID Number  
 Body style  
 How is vehicle primarily used?  
 If Business, describe type of business  
 If Commute, how many miles one way?  
 Lien holder
 Name  
 Address  
 Phone #  
 Fax #  
 Loan #  
 Select coverage and limits below
 Liability      
 Un(der)insured Motorist   Will Match Liability Selection
 Medical  
 Personal Injury Protection  
 Comprehensive     
 Collision               
 Towing  Company Will Provide Limits
 Rental Reimbursement  Company Will Provide Limits
 Please use the space below to add comments regarding any special circumstances or coverage needs

 When you are finished, press SEND only once. It may take a few moments to process the form. You may also wish to use PRINT, which will open the form in a new window and allow you to print the information for your records or to submit the information in person or via fax.

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