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Blue Cross and Blue Shield of IL
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2018-02-19T17:14:42-06:00
Classic Car Quote
Step
1
of
10
10%
Producer Information
Producer Name
*
First
Last
Producer Phone Number
*
Producer Email
*
Enter Email
Confirm Email
How many years has the Producer known the applicant?
*
1 Year
1-3 Years
3+ Years
Insured Personal Information
Requested Effective Date
MM slash DD slash YYYY
Insured's Name
*
First
Last
Phone Number
Insured's Email
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Occupation
Accounting/Finance
Advertising/Public Relations
Aerospace/Aviation
Arts/Entertainment/Publishing
Automotive
Banking/Mortgage
Business Development
Business Opportunity
Clerical/Administrative
Construction/Facilities
Consumer Goods
Customer Service
Education/Training
Energy/Utilities
Engineering
Government/Military
Green
Healthcare
Hospitality/Travel
Human Resources
Installation/Maintenance
Insurance
Internet
Job Search Aids
Law Enforcement/Security
Legal
Management/Executive
Manufacturing/Operations
Marketing
Non-Profit/Volunteer
Pharmaceutical/Biotech
Professional Services
QA/Quality Control
Real Estate
Restaurant/Food Service
Retail
Sales
Science/Research
Skilled Labor
Technology
Telecommunications
Transportation/Logistics
Other
Gender
Mail
Female
Highest Education Completed?
*
High School
Associate's Degree
Bachelor's Degree
Law or Medical Degree
Does the insured own or rent their home?
*
Own
Rent
How many years at current residence?
DOB
*
Insured SSN:
*
Insurance Information
Current Carrier
*
Number of years with Carrier
*
Expiration Date
*
Premium
*
Driving Activity
Any Tickets/Accidents in the past 3 years?
*
Yes
No
Please tell us about any tickets or accidents the driver has been in
*
License Ever Suspended?
*
Yes
No
Vehicle Information
Vehicle 1
Stock or Modified
Stock
Modified
Year
*
Make
*
Model
*
VIN
*
Agreed Value
*
Annual Miles
*
Buy new or used?
*
New
Used
Date Purchased
*
Month
Day
Year
Add 2nd vehicle?
*
Yes
No
Vehicle 2
Stock or Modified
Stock
Modified
Year
*
Make
*
Model
*
VIN
*
Agreed Value
*
Annual Miles
*
Buy new or used?
*
New
Used
Date Purchased
*
Month
Day
Year
Add 3rd vehicle?
*
Yes
No
Vehicle 3
Stock or Modified
*
Stock
Modified
Year
*
Make
*
Model
*
VIN
*
Agreed Value
*
Annual Miles
*
Buy new or used?
*
New
Used
Date Purchased
*
Month
Day
Year
Add 4th vehicle?
*
Yes
No
Vehicle 4
Stock or Modified
*
Stock
Modified
Year
*
Make
*
Model
*
VIN
*
Agreed Value
*
Annual Miles
*
Buy new or used?
*
New
Used
Date Purchased
*
Month
Day
Year
Coverage Limits
Coverage Limits Are the same for ALL vehicles?
*
Yes
No
Bodily Injury
*
No Coverage
50/100
100/300
250/500
500/500
Property Damage
*
No Coverage
50
100
250
UM/IM
*
No Coverage
50/100
100/300
250/500
Medical Payments
*
No Coverage
2,500
5,000
10,000
UMPD
*
Yes
No
UMPD Limits
*
15
20
25
50
100
Towing
Yes
No
Rental Reimbursement
*
No Coverage
25/750
30/1050
50/1500
75/2250
Comprehensive Deductible
*
No Coverage
50
100
200
250
500
1,000
Collision Deductible
*
No Coverage
250
500
1,000
For personal umbrella coverage, please select limit
*
No Coverage
$1 Million
$2 Million
$3 Million
Coverage Limits Vehicle 2
Bodily Injury
*
No Coverage
50/100
100/300
250/500
500/500
Property Damage
*
No Coverage
50
100
250
Medical Payments
*
No Coverage
2,500
5,000
10,000
UM/IM
*
No Coverage
50/100
100/300
250/500
UMPD
*
Yes
No
UMPD Limits
*
15
20
25
50
100
Towing
Yes
No
Rental Reimbursement
*
No Coverage
25/750
30/1050
50/1500
75/2250
Comprehensive Deductible
*
No Coverage
50
100
200
250
500
1,000
Collision Deductible
*
No Coverage
250
500
1,000
For personal umbrella coverage, please select limit
*
No Coverage
$1 Million
$2 Million
$3 Million
Coverage Limits Vehicle 3
Bodily Injury
*
No Coverage
50/100
100/300
250/500
500/500
Property Damage
*
No Coverage
50
100
250
Medical Payments
*
No Coverage
2,500
5,000
10,000
UM/IM
*
No Coverage
50/100
100/300
250/500
UMPD
*
Yes
No
UMPD Limits
*
15
20
25
50
100
Towing
Yes
No
Rental Reimbursement
*
No Coverage
25/750
30/1050
50/1500
75/2250
Comprehensive Deductible
*
No Coverage
50
100
200
250
500
1,000
Collision Deductible
*
No Coverage
250
500
1,000
For personal umbrella coverage, please select limit
*
No Coverage
$1 Million
$2 Million
$3 Million
Coverage Limits Vehicle 4
Bodily Injury
*
No Coverage
50/100
100/300
250/500
500/500
Property Damage
*
No Coverage
50
100
250
Medical Payments
*
No Coverage
2,500
5,000
10,000
UM/IM
*
No Coverage
50/100
100/300
250/500
UMPD
*
Yes
No
UMPD Limits
*
15
20
25
50
100
Towing
Yes
No
Rental Reimbursement
*
No Coverage
25/750
30/1050
50/1500
75/2250
Comprehensive Deductible
*
No Coverage
50
100
200
250
500
1,000
Collision Deductible
*
No Coverage
250
500
1,000
For personal umbrella coverage, please select limit
*
No Coverage
$1 Million
$2 Million
$3 Million
Has coverage been cancelled or renewed in the past three years?
Yes
No
Please provide the reason for canceling or renewing
*
Please enter any additional information you may have regarding this quote.
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