Renters & Auto Quote - Midwest Insurance Brokerage Services Inc

Producer Information

Insured Personal Information

Limits

Building Information

Property Details

Homeowner's Claims

Current Carrier Information

Auto Carrier Information

Driver Information

Vehicle Information

Coverage Limits

Review

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Renters & Auto Bundled Quote

Step 1 of 12 - Producer Information

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

Requested Effective Date(Required)

Month

Day

Year

Insured's Name(Required)

First Last

DOB(Required)

Phone Number

Insured's Email

Address(Required)

Street Address Address Line 2 City State ZIP Code

Occupation(Required)

Highest Education Completed?(Required)

Previous Address (if less than 1 year at current address)

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?

Insured SSN: (Required for Rockford Mutual)

Renters Coverage Limits

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

Liability Limit(Required)

Medical Payments(Required)

Deductible(Required)

Water Back-up Limit(Required)

Jewelry/Valueable items PAF amount(Required)

Renters Building Information

Year Built(Required)

Year Rented(Required)

Square Footage(Required)

Number of Stories (In building)(Required)

Number of Units (In building)

Construction Type(Required)

Roof Type(Required)

Heat Type(Required)

Breakers

Fuses

Renters Property Information

Any business in the home?

Yes

Describe business(Required)

Does the Insured have any pets?

Yes

How Many?

Does the rental 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

Renters / 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.

Renters Current Carrier Information

Current Carrier(Required)

Premium

Expiration Date

Additional information regarding the renters 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

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Contact

Phone (847) 427-8000

Email info@midwestga.com

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Applied Pay

Need Help?

(847) 427-8000

Producer Information

Insured Personal Information

Renters Coverage Limits

Renters Building Information

Renters Property Information

Renters / Homeowners Claims Information

Renters 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