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UNIVERSAL INSURANCE SERVICES
3342 W. LAWRENCE CHICAGO, IL 60625
CALL TODAY
773-539-0900
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Fields marked with "*" are required |
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Name* |
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Street Address:* |
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City:* |
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State |
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Zip Code:* |
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Phone:* |
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Email: |
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Occupation |
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Term Requested: |
6 Months
12 Months |
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Automobiles |
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Vehicle 1) Year:* |
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Make/Model:* |
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VIN Number: |
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Vehicle 2) Year: |
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Make/Model: |
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VIN Number: |
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Vehicle 3) Year: |
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Make/Model: |
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VIN Number: |
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Drivers Information |
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Name
(Include Yourself) |
Date of Birth |
Driver's License (*) |
Sex |
Marital Status |
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Moving violations, accidents, revocations or suspensions in the past
36 months? List and describe all incidents applied to listed
drivers. |
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Currently Insured? |
Yes
No |
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How long with current carrier? |
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Previous Insurance Carrier: |
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Coverages: |
Mandatory Liability
Yes |
Choose this option if you want ONLY the mandatory liability required
by law.
Minimum Coverage Required By Illinois Law:
Bodily Injury $20/40,000
Liability Property Damage $15,000
Uninsured Motorist $20/40,000
OR, Select Liability amounts below. |
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Liability Amount |
$
,000 Bodily Injury
$ ,000 Property Damage
$ Medical Payments
$ ,000 Uninsured/Underinsured Motorist |
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Comprehensive/Collision |
Deductible |
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Automobile 1
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Automobile 2 |
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Automobile 3 |
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Towing & Labor Costs: |
Yes
No |
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Auto Rental: |
Yes
No |
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Traffic Bond Card: |
Yes
No |
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Financial Responsibility Filing ( SR-22 ): |
Yes
No |
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If SR-22 answered yes, please supply reason: |
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How would you like to be contacted?
Phone
Fax
Email |
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Questions / Comments / Remarks? |
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By submitting this form for processing I warrant that the statements
contained herein are true and correct.
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If you prefer to fax this application,
our fax number is 773-539-5396. |
