Condo & Auto Quote - Midwest Insurance Brokerage Services Inc

Producer Information

Insured Personal Information

Insured Amounts

Property Information

Property Details

Utilities

Homeowners Claims Information

Mortgage Information

Carrier Information

Driver Information

Vehicle Information

Coverage Limits

Review

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(847) 427-8000

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Condo & Auto Bundled Quote

Step 1 of 13 - Producer Information

Requested Effective Date(Required)

Month

Day

Year

Producer Information

Producer Name(Required)

First Last

Producer Phone Number(Required)

Producer Email(Required)

Enter Email Confirm Email

How many years has the Producer known the applicant?(Required)

1 Year

1-3 Years

3+ Years

Insured Personal Information

Insured's Name(Required)

First Last

Phone Number

Insured's Email

Address(Required)

Street Address Address Line 2 City State ZIP Code

Highest Education Completed?(Required)

High School

Associate's Degree

Bachelor's Degree

Law or Medical Degree

Insured SSN: (Required for Rockford Mutual)

Occupation(s)

DOB(Required)

Month

Day

Year

Marital Status(Required)

Have you moved in the last 12 months?(Required)

Yes

Previous Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Does the insured own or rent their home?(Required)

Own

Rent

How many years at current residence?

Condo Coverage Limits

Amount to be quoted on Interior Building Property(Required)

Amount to be quoted on Personal Property/Contents(Required)

Loss Assessment(Required)

Water Back-up Limit(Required)

Liability Limit(Required)

Deductible(Required)

Jewelry/Furs/Fine Arts Etc(Required)

Medical Payments(Required)

Condo Property Information

Year Built(Required)

Purchase Date(Required)

Month

Day

Year

Purchase Price(Required)

Number of Bathrooms(specify full and half bathrooms)(Required)

Number of Stories (building)(Required)

Number of Units (building)(Required)

Center or End Unit?(Required)

Center Unit

End Unit

Square Footage(Required)

Construction Type(Required)

Frame

Aluminum/Vinyl Siding

Masonry

Masonry Veneer

Roof Type(Required)

Tile/Slate

Asphalt Shingle

Wood Shingle

Tar & Gravel

Condo Features and Household Information

Does the condo unit have any of the following?

Central/Monitored burglar/fire alarm

Smoke Detectors

Fire Extinguishers

Dead Bolt Locks

Items must be in the unit, not the common areas.

Does the Insured have any dogs?(Required)

Yes

Breed Of Dog(s)(Required)

How Many?

Any business in the home?

Yes

If yes, please describe

Condo Utilities

Is the Property more than 15 years old?(Required)

Yes

When were the utilities last updated? if never updated, please provide the date the utility was put in the home

Furnace(Required)

Electrical(Required)

Plumbing(Required)

Roof(Required)

Please select either Breakers or Fuses(Required)

Breakers

Fuses

Condo / Homeowners Claims Information

Any HO claims in the past 5 years?(Required)

Please explain (date/type of loss/amount paid)(Required)

Please provide details such as the date, the type of loss, and the amount paid.

Condo Mortgage and Current Carrier Information

Current Mortgage Company

Mortgagee Bill?(Required)

Yes

Mortgage Company Name(Required)

Current Carrier(Required)

Number of years with Carrier

Expiration Date(Required)

Month

Day

Year

Premium

Has coverage been cancelled or non-renewed in the last 3 years?(Required)

Please provide reason for coverage being cancelled or non-renewed(Required)

Additional information regarding the condo quote

Auto Carrier Information

Current Carrier(Required)

Number of years with Carrier(Required)

Renewal Date(Required)

Premium(Required)

Is current policy 6 month or 12 month?(Required)

6 Month

12 Month

Other

Driver Information

ALL LICENSED AGE HOUSEHOLD MEMBERS MUST BE LISTED ON THE POLICY, EVEN IF THEY DON'T DRIVE

Driver 1

Name(Required)

First Last

Relationship to Insured(Required)

Indicate: Self, Spouse, Child, Other (and describe)

Gender(Required)

Male

Female

DOB(Required)

Driver's License #(Required)

Marital Status(Required)

Married

Single

Divorced

Widowed

Occupation(Required)

Is the Driver a good Student?(Required)

Yes

Is the Driver away at School(Required)

Yes

Please explain any tickets the driver has recieved?(Required)

Please tell us about any accidents the driver has been in(Required)

Add Another Driver?(Required)

Yes

Driver 2

Name(Required)

First Last

Relationship to Insured(Required)

Indicate: Self, Spouse, Child, Other (and describe)

Gender(Required)

Male

Female

DOB(Required)

Driver's License #(Required)

Marital Status(Required)

Married

Single

Divorced

Occupation(Required)

Is the Driver a good Student?(Required)

Yes

Is the Driver away at School?(Required)

Yes

Please explain any tickets the driver has recieved?(Required)

Please tell us about any accidents the driver has been in(Required)

Add a third Driver?(Required)

Yes

Driver 3

Name(Required)

First Last

Relationship to Insured(Required)

Indicate: Self, Spouse, Child, Other (and describe)

Gender(Required)

Male

Female

DOB(Required)

Driver's License #(Required)

Marital Status(Required)

Married

Single

Divorced

Occupation(Required)

Is the Driver a good Student?(Required)

Yes

Is the Driver away at School?(Required)

Yes

Please explain any tickets the driver has recieved?(Required)

Please tell us about any accidents the driver has been in(Required)

Add a fourth Driver?(Required)

Yes

Driver 4

Name(Required)

First Last

Relationship to Insured(Required)

Indicate: Self, Spouse, Child, Other (and describe)

Gender(Required)

Male

Female

Date Of Birth(Required)

Driver's License #(Required)

Marital Status(Required)

Married

Single

Divorced

Occupation(Required)

Is the Driver a good Student?(Required)

Yes

Is the Driver away at School?(Required)

Yes

Please explain any tickets the driver has recieved?(Required)

Please tell us about any accidents the driver has been in(Required)

Vehicle Information

Vehicle 1

Year(Required)

Make(Required)

Model(Required)

VIN(Required)

Vehicle Title(Required)

Primary Driver(Required)

Vehicle Use(Required)

Pleasure

Work

School

How does driver commute to and from Work/School(Required)

Bus

Train

Works From Home

Milage 1 Way(Required)

Add 2nd vehicle?(Required)

Yes

Vehicle 2

Year(Required)

Make(Required)

Model(Required)

VIN(Required)

Vehicle Title(Required)

Primary Driver(Required)

Vehicle Use(Required)

Pleasure

Work

School

How does driver commute to and from Work/School(Required)

Bus

Train

Works From Home

Milage 1 Way(Required)

Add 3rd vehicle?(Required)

Yes

Vehicle 3

Year(Required)

Make(Required)

Model(Required)

VIN(Required)

Vehicle Title(Required)

Primary Driver(Required)

Vehicle Use(Required)

Pleasure

Work

School

How does driver commute to and from Work/School(Required)

Bus

Train

Works From Home

Milage 1 Way(Required)

Add 4th vehicle?(Required)

Yes

Vehicle 4

Year(Required)

Make(Required)

Model(Required)

VIN(Required)

Vehicle Title(Required)

Primary Driver(Required)

Vehicle Use(Required)

Pleasure

Work

School

How does driver commute to and from Work/School(Required)

Bus

Train

Works From Home

Milage 1 Way(Required)

Coverage Limits

Coverage Limits Are the same for ALL vehicles?(Required)

Yes

CSL(Required)

Yes

If yes, limit:

OR split limits (if yes, indicate split limits below)(Required)

Yes

Bodily Injury

Property Damage

Medical Payments

UM/IM

Comprehensive Deductible(Required)

Collision Deductible(Required)

Emergency Roadside Service(Required)

Rental Reinbursment(Required)

If Liability Only: UM Physical Damage(Required)

Glass Coverage(Required)

For personal umbrella coverage, please select limit(Required)

Coverage Limits Vehicle 2

CSL(Required)

Yes

If yes, limit:

OR split limits (if yes, indicate split limits below)(Required)

Yes

Bodily Injury

Property Damage

Medical Payments

UM/IM

Comprehensive Deductible(Required)

Collision Deductible(Required)

Emergency Roadside Service(Required)

Rental Reinbursment(Required)

If Liability Only: UM Physical Damage(Required)

Glass Coverage(Required)

For personal umbrella coverage, please select limit(Required)

Coverage Limits Vehicle 3

CSL(Required)

Yes

If yes, limit:

OR split limits (if yes, indicate split limits below)(Required)

Yes

Bodily Injury

Property Damage

Medical Payments

UM/IM

Comprehensive Deductible(Required)

Collision Deductible(Required)

Emergency Roadside Service(Required)

Rental Reinbursment(Required)

If Liability Only: UM Physical Damage(Required)

Glass Coverage(Required)

For personal umbrella coverage, please select limit(Required)

Coverage Limits Vehicle 4

CSL(Required)

Yes

If yes, limit:

OR split limits (if yes, indicate split limits below)(Required)

Yes

Bodily Injury

Property Damage

Medical Payments

UM/IM

Comprehensive Deductible(Required)

Collision Deductible(Required)

Emergency Roadside Service(Required)

Rental Reinbursment(Required)

If Liability Only: UM Physical Damage(Required)

Glass Coverage(Required)

For personal umbrella coverage, please select limit(Required)

Has coverage been cancelled or non-renewed in the past three years?

Yes

Please provide the reason for canceling or renewing(Required)

Does insured or household member drive a company car?(Required)

Yes

Please Provide Carrier(Required)

Company Car Limits(Required)

Policy Effective Date(Required)

Month

Day

Year

Company Car Policy Effective Date

Expiration Date(Required)

Month

Day

Year

Company Car Policy Expiration Date

Additional information regarding the auto quote

Products

Health Customer Service

P&C Customer Service

Contact

Phone (847) 427-8000

Email info@midwestga.com

Group Health

Blue Cross Blue Shield of IL

United Health Care Level Funded

BCBSIL Dental & Vision

Principal Dental & Vision

UNUM Dental & Vision

VSP Vision

View More HSA information

Under 65

Blue Cross Blue Shield of IL

United Healthcare

Over 65

Blue Cross Blue Shield of IL

Aetna

United Healthcare

Healthspring

Ancillary

Blue Cross Blue Shield of IL Dental

Travel Insurance

HSA

View HSA Information

Service Center

Service Center

Personal Lines Forms & Resources

Service Center

Service Center

Commercial Lines forms & Resources

CNA Training Videos

Applied Pay

Need Help?

(847) 427-8000

Producer Information

Insured Personal Information

Condo Coverage Limits

Condo Property Information

Condo Features and Household Information

Condo Utilities

When were the utilities last updated? if never updated, please provide the date the utility was put in the home

Condo / Homeowners Claims Information

Condo Mortgage and Current Carrier Information

Auto Carrier Information

Driver Information

Driver 1

Driver 2

Driver 3

Driver 4

Vehicle Information

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Coverage Limits

Coverage Limits Vehicle 2

Coverage Limits Vehicle 3

Coverage Limits Vehicle 4