LaVan Insurance Agency

Auto Insurance Quote
Please fill out the form below and we will in contact with you within the next business day.

Applicant / Titleholder

Last Name:		Pref Language:
First Name:
Address:		Phone:
City:		Email:
State:		How would you like us to contact you?
Zip:		How did you hear about us?

Current Insurance

Do you currently have insurance? How long without a lapse in coverage?
If YES, please complete the following:
	Company Name:
	Number of months claim free:
	Number of months with them:

Drivers

Required Info	Driver 1	Driver 2	Driver 3	Driver 4
First Name:
Last Name:
Date of Birth:
Sex / Martial Sts:
Time Licensed:
Driving Record: (last 3 years)
Date of Incident1:
MVR Incident 1 Description:
Date of Incident2:
MVR Incident 2 Description:
Date of Incident3:
MVR Incident 3 Description:
Notes/Comments:
More drivers?
Notes:
If more than 4 drivers are required, we will contact you for the additional information.

Vehicles

Required Info	Vehicle 1	Vehicle 2	Vehicle 3	Vehicle 4
Year:
Make:
Model:
VIN #:
Roof Feature:
Conversion Van?
More vehicles?
Notes:
If more than 4 vehicles are required, we will contact you for the additional information.

Coverages - Liability

Required Info	Vehicle 1	Vehicle 2	Vehicle 3	Vehicle 4
Bodily Injury:		(This coverage will apply to all vehicles on the policy.)
Property Damage:		(This coverage will apply to all vehicles on the policy.)
Medical Payments:		(This coverage will apply to all vehicles on the policy.)
Uninsured Motorist:		(This coverage will apply to all vehicles on the policy.)
Underins Motorist:		(This coverage will apply to all vehicles on the policy.)
UM Property Damge:
*minimum required limits in Illinois

Coverages - Physical Damage

Required Info	Vehicle 1	Vehicle 2	Vehicle 3	Vehicle 4
Collision Deductible:
Comprehensive Ded:	(The comprehensive deductible will match the collision deductible)
Towing Reimburmnt:
Rental Reimburmnt:

Comments:

Thank you for taking the time to complete this form. We will be in contact with you as soon as we have your quote ready.