Auto Insurance Quote

Please fill out the form below as completely as possible. Once you have completed the form, click Submit to send your information to Marcussen Insurance Service. We will handle your request shortly, and you will receive a call back from us.

Or just call us at (309)764-6850 for a quote.

Fields marked with an * are required.

General Information
* Are all vehicles listed in your name?	yes no
* Do you currently have auto insurance?	yes no
If yes, please list the carrier and how long you have been with them:

Carrier:	Length of Prior:
* Do you own or rent your home?
* Are you currently employed?

Personal Information
* First, MI, Last Name:	E-mail:	* Phone Number:

* Birthdate: (mm/dd/yyyy)

* Driver's License Number:

* Street Address:

* City:

* State:

* Zipcode:

How long have you lived at your current address?
If less than six months, please provide your previous address:

* Is there anyone Fifteen and over living with you?

yes no

Please list their names, birthdates, and Driver's License #'s if they will be driving.

First, MI, Last Name:	Birthdate:	Driver's License Number
			Rated Excluded
			Rated Excluded
			Rated Excluded

Accidents and Violations

* Have you had any accidents or violations in the past 5 years?

yes no

If yes, please list the date(s) and what type of accident(s) or violation(s) occurred.

Driver #1		Driver #2		Driver #3
Date:	Acc/Viol:	Date:	Acc/Viol:	Date:	Acc/Viol:

Vehicle Information

Vehicle #1
* Year:	* Make:	* Model:	VIN #:

If there is a loan, please list the lienholder:

Vehicle #2
* Year:	* Make:	* Model:	VIN #:

If there is a loan, please list the lienholder:

Vehicle #3
* Year:	* Make:	* Model:	VIN #:

If there is a loan, please list the lienholder:

Coverages

* Liability limits must be the same for all vehicles.

Vehicle #1	Vehicle #2	Vehicle #3
* Liability Limits: Comprehensive Deductible: Collision Deductible: Towing: Rental: Medical Coverages:	Comprehensive Deductible: Collision Deductible: Towing: Rental: Medical Coverages:	Comprehensive Deductible: Collision Deductible: Towing: Rental: Medical Coverages:

When is the best time for us to contact you?:

Auto Insurance Quote

General Information

Personal Information

Accidents and Violations

Vehicle Information

Vehicle #1

Vehicle #2

Vehicle #3

Coverages

Vehicle #1

Vehicle #2

Vehicle #3