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Personal Umbrella Insurance Quote

Personal Information
Name:*
Address:
Street Address City State ZIP Code
Phone:*
Email:*
Are You Currently Insured?:
- Yes
- No
Current Insurance Information
Insurance Company Name (not agency):
Policy Expiration Date:
Month
Day
Year
Years Insured:
Premium Amount:
General Information
Any Driver with Mental - Physical Impairments?
- Yes
- No
Please Explain:
Any Premises, Vehicles, Watercraft, Aircraft Used For Business?
- Yes
- No
Please Explain:
Do you Engage in Any Type of Farming Operation?
- Yes
- No
Please Explain:
Do You Hold Any Non-Remunerative Postitions?
- Yes
- No
Please Explain:
Any Aircraft Owned, Leased, Chartered or Furnished for Regular Use??
- Yes
- No
Please Explain:
Do You Emply Any Residence Employees?
- Yes
- No
(i.e. Housekeeper)
Please Explain:
Any Non-Owned Property Exceeding $1,000 in Value in Your Care, Custody or Control?
- Yes
- No
Please Explain:
Any Non-Owned Business or Professional Activities Included in the Primary Policies?
- Yes
- No
Please Explain:
Does Any Primary Policy Have Reduced Limits of Liability or Eliminate Coverage for Specific Exposures?
- Yes
- No
Please Explain:
Was Any Coverage Declined, Cancelled or Non-Renewed Within the Past 5 Years?
- Yes
- No
Please Explain:
Any Motorcycles, Mopeds or All Terrain Vehicles Owned?
- Yes
- No
Please Explain:
Any Youthful Drivers Under the Age of 25?
- Yes
- No
Please Explain:
Any Other Business Activities Conducted From Your Residence or Premises?
- Yes
- No
Please Explain:
Driver Information
How many licensed drivers in your household?
- 1
- 2
- 3
- 4
Driver #1 Information
Drivers Name:
First Last
Relation:
Years Licensed:
Date of Birth:
Gender:
- Male
- Female
Marital Status:
- Married
- Single
Drivers Education:
- Yes
- No
Has this drivers license ever been suspended or revoked?
- No
- Yes, Suspended
- Yes, Revoked
- Yes, Both
Has this driver ever been convicted of a DUI?
- No
- Yes, For Drugs
- Yes, For Alcohol
- Yes, Both
Driver #2 Information
Drivers Name:
First Last
Relation:
Years Licensed:
Date of Birth:
Gender:
- Male
- Female
Marital Status:
- Married
- Single
Drivers Education:
- Yes
- No
Has this drivers license ever been suspended or revoked?
- No
- Yes, Suspended
- Yes, Revoked
- Yes, Both
Has this driver ever been convicted of a DUI?
- No
- Yes, For Drugs
- Yes, For Alcohol
- Yes, Both
Driver #3 Information
Drivers Name:
First Last
Relation:
Years Licensed:
Date of Birth:
Gender:
- Male
- Female
Marital Status:
- Married
- Single
Drivers Education:
- Yes
- No
Has this drivers license ever been suspended or revoked?
- No
- Yes, Suspended
- Yes, Revoked
- Yes, Both
Has this driver ever been convicted of a DUI?
- No
- Yes, For Drugs
- Yes, For Alcohol
- Yes, Both
Driver #4 Information
Drivers Name:
First Last
Relation:
Years Licensed:
Date of Birth:
Gender:
- Male
- Female
Marital Status:
- Married
- Single
Drivers Education:
- Yes
- No
Has this drivers license ever been suspended or revoked?
- No
- Yes, Suspended
- Yes, Revoked
- Yes, Both
Has this driver ever been convicted of a DUI?
- No
- Yes, For Drugs
- Yes, For Alcohol
- Yes, Both
Vehicle Information
(All cars you or your family members own or lease)
List Vehicles:
Year: Make: Model: Body Type:
Driving History
Please list any convictions for any driver convicted of moving traffic violations in the past 3 years.
Driver Name: Date: Type of Conviction: Fines ($): Over Limit (mph):
Miscellaneous:
No. of Single Family Dwellings You Own:
No. of Multi-Unit Buildings You Own:
No. of Vacant Property (land) You Own:
No. of Autos You Own:
No. of Motorcycles You Own:
No. of Watercraft You Own:
No. of Recreational Vehicles You Own:
Liability Limits Requested:
Losses-Claims in the last 5 years:
Please explain amount paid and describe first loss claim:
Additional Comments or Questions
Phone
This field is for validation purposes and should be left unchanged.

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Shelbyville Office

Koonce Insurance Agency

1604 W Main Street
Suite 300
Shelbyville, Illinois 62565

Mailing Address
P.O. Box 476
Shelbyville, Illinois 62565

Phone: (217) 774-5581

Mon-Fri: 8:30am-5:00pm
Sat-Sun: Closed

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Mattoon Office

Koonce Insurance Agency

1404 Broadway Avenue
Mattoon, Illinois 61938

Phone: (217) 235-3167

Fax: (217) 235-3168

Mon-Fri: 8:30am-5:00pm
Sat-Sun: Closed

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Pana Office

Koonce Insurance Agency

306A East 1st Street
Pana, Illinois 62557

Phone: (217) 562-4010

Mon-Fri: 8:30am-5:00pm
Sat-Sun: Closed

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Koonce Insurance Agency provides auto insurance, home insurance, life insurance, health insurance, business insurance, and employee benefits to all of Illinois, including Shelbyville, Pana, Taylorville, Sullivan, Mattoon, Charleston, Effingham, Decatur, Mt. Zion, and Vandalia.

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