Marvell-Tower Insurance Agencies
Provider of low cost auto isurance, Imediate liability binders, Same day SR 22, Easy payment plans for both cars and motorcycles
 
435 N. LaSalle St
Chicago, IL 60610
312-462-1200
312-467-9272 (fax)
E-mail:sales@marvelltower.com

Our agency is licensed to quote and write insurance policies only in Illinois. To find agents offering these coverages in all other states, please click the IQ.net logo.

 
 Automobile Insurance Quote
Completely fill out and submit this form to our agency to receive an accurate quote. You MUST provide at least one method of contact to receive a quote from our agency.

General Policy Information
 Name: (required)  
 E-Mail Address: (required)  
 Street:  
 City: (required)  
 County:  
 State:(required)   Zip: (required)
 Day Phone:  
 Evening Phone:  
 FAX:  
  What month current policy expire?  
  What is the name current insurance company?  
Check this box to grant our agency permission to secure your credit and/or claim history, for insurance purposes only, under the Fair Credit Reporting Act. Your name  
In order to provide a PREFERRED policy quote some of the companies that we represent may require a credit and/or claims history. For Preferred quotes, Social Security numbers are required. You do not have to provide social security numbers at this time but we can't guarantee that we can provide the best price available until after we speak with you and secure this credit and/or claim information. 
       
 How do you describe your credit rating    
 What level of education did you complete?      Your spouse?  
  What is your occupation?       Your spouse?  
  Do you own (or buying) your home?      

 

Vehicle Information

Please provide vehicles year, make, model Response Format : 2002, Ford, Explorer

All of this information is necessary to receive a accurate quotation

 Veh   Year - Make - Model    Vehicle equipped with:
Anti Theft  Anti Lock Brakes Running Lights
  How is this car used?   Vehicle Identification Number 

 

Annual
Miles
 1
   
2 
   
3 
   
 
4 
   
 

Please provide this information about household's drivers
 #   First Name    Gender  Birth Date 

 

Married
Status

 

Social
Security # 
  Principal Driver of Vehicle #
 1             
 2             
 3            
 4            

The following information is optional, but if provided we will be able to give you with a more accurate premium quotation.
   
 Drivers' License Information:
 Driver #
 License Number
(required in California) 
Years Licensed
(required in California) 
 1  

 
 2  

 
 3  

 
 4  

 

Tell us about your coverages requirements
 Comprehensive Deductible  
 Collision Deductible  

Bodily Injury Liability Limit (000)

or Combined Single Limit (CSI)

Currently carry?
Property Damage Liability Limit

Currently carry?
 Uninsured Motorist Bodily Injury Liability (000)  
 Uninsured Motorist Property Damage Liability  
 Personal Injury Protection  
 Medical Payments  
 Road Service Coverage  
 Rental Car Reimbursement  

Accidents / Violations & Underwriting Info
Type of Violation Driver 1 Driver 2 Driver 3 Driver 4
Minor Violations - Speeding, Illegal Turn, Stop Sign, Red Light, etc.
Within the last 3 years
Dates
MM/DD/YY
Dates
MM/DD/YY
Dates
MM/DD/YY
Dates
MM/DD/YY
Major Violations - Drunk Driving, Reckless, Hit & Run, Speeding - Greater than 30 MPH over limit
Within the last 5 years
 
Dates
MM/DD/YY
 
Dates
MM/DD/YY
 
Dates
MM/DD/YY
 
Dates
MM/DD/YY
Accidents - Non Chargeable
Within the last 3 years
Dates
MM/DD/YY
Dates
MM/DD/YY
Dates
MM/DD/YY
Dates
MM/DD/YY
Accidents - Chargeable
Within the last 3 years
Dates
MM/DD/YY
Dates
MM/DD/YY
Dates
MM/DD/YY
Dates
MM/DD/YY
Please use this area to give us any additional information that you may feel is important for your insurance.
ie: Is one of your cars used to deliver pizzas or conduct another type of business? Do your young drivers have a B average or better in school?
Are there any additional cars or drivers? Provide info here.


 

This page and site has been developed and maintained by InsuranceQuote.Net
© Gordon K. Harden, Jr. 1996-2003
mail to: gkh@InsuranceQuote.net
 
 
Page Created 7-6-01
 
 
Latest Revision 6-01-03