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REQUEST A QUOTE  --  Standard Auto

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.

Social Security Number     (optional)



E-Mail Address

Do you own   or rent your home?


Years Driving Experience    Gender      Marital Status

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

Name Other Driver(s) in Household 
 #2   #3   #4   #5   
  #3   #4   #5 
Birth Date:
  #3   #4   #5    
Marital Status:
  #3   #4   #5 
Years Driving Experience:
  #3   #4   #5    
Name & Date Any Accidents or Moving Violations, last 3 years:


Make & Model of Vehicle Year
Engine Size (cc)    Any Liens/Leases? 

Estimated Annual Mileage  Garaged Zip

Additional Vehicles  

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
P.O. Box 14   Oregon, IL   61061


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