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Request A Quote  --  Antique & Classic
         (Vehicles 19 years Old and Older)
 

Click here to download a Microsoft Word printable "Request for Quote" form that you can mail in.

 

Or, fill out the below form and hit "submit".

 

Primary Driver    Phone

Address    Date of Birth   

City     State    Zip   
Quotes provided for Illinois, Iowa and Wisconsin residents only.

E-Mail Address

Social Security Number     (optional)

County    Do you own   or rent your home?

Years Auto Driving Experience    Gender    Marital Status

Name & Date any Accidents or Moving Violations in the last 5 Years:


List Memberships in Collectable Clubs and Organizations 

Name Other Driver(s) in Household 
 #2   #3   #4   #5    
Gender:
 #2
  #3   #4   #5 
Birth Date:
 #2
  #3   #4   #5    
Marital Status:
 #2
  #3   #4   #5 
Years Driving Experience:
 #2
  #3   #4   #5    

List Vehicles used for Daily Transportation Year, Make & Model
 
   

Make & Model of Antique/Classic Vehicle 
Year  

Engine Size (cc) List any Engine Modifications 

List any other Restorations or Modifications

Current Market Value     Any Liens/Leases? 

Estimated Annual Mileage  Garaged Zip

Is the Antique/Classic Vehicle driven to work, to school. to shop or run daily errands? 

For what purpose(s) is the Antique/Classic Vehicle driven? 

Desired Effective Insurance Date 

Name Existing Insurance Carrier on this Vehicle, if any 

Liability/PD Coverage?  20/40/15     25/50/25     50/100/50    100/300/100
                      
250/500/250

Uninsured/Underinsured Coverage Same as Liability, unless requested otherwise:
 

Medical Payments?   None    1000    2500    5000    10,000   

Comprehensive (fire & theft)?  Yes   No   Deductible  250   500    1000   

Collision?      Yes    No    Deductible   250    500    1000   

 

Other Notes and Information:

Note: When providing a quotation for an insurance premium, insurance companies may review your credit report and your driving record. No insurance coverage is bound until a) we provide a quote using the information provided here and b) we receive your completed application and premium payment.


Voice  630-204-4178    Fax  815-732-1320
info@callriderschoice.com
P.O. Box 14   Oregon, IL   61061

             
             
             

Copyright 2004-2006, Riders Choice Insurance Agency, Inc., all rights reserved