All the information requested on this page is available on the DEC page (declarations page) of your policy. Some insurance carriers also list this information on the card they provide to you as proof of insurance. In Illinois, insurance is not just a good idea, it is the law!

Name of driver number one:
Date of Birth:
What company insures your auto now?:
What is your expiration date?:
Driver # 1 Sex: Female Male
Driver # 1 Marital Status: Married Single

List all accidents and/or moving violations for past five years with date and approximate dollar amount paid on any accident claim. Please indicate what driver corresponds with each ticket and/or accident:

Auto Description Auto # 1

List The Auto Driver Number One Drives as Auto Number One:
List The Auto Driver Number Two Drives as Auto Number Two.

Auto #1 Year, Make, Model and Body Style:
Vehicle Identification Number:
Annual Mileage Driven:
Number of miles driven to work or school one way:
Alarm Auto #1: YES NO
Alarm Type Auto #1. Give a short description of alarm:
Anti-Lock Brakes Auto #1: Y N
Driverside Airbag Auto #1: Y N
Passengerside Airbag Auto #1: Y N
Is Auto #1 Used For Business: Y N

Coverage Limits Auto # 1

Liability for Bodily Injury. Auto #1: $20,000 each person $40,000 each accident $25,000 each person $50,000 each accident $50,000 each person $100,000 each accident $100,000 each person $300,000 each accident
Property Damage, Auto #1 : $15,000 each accident $25,000 each accident $50,000 each accident $100,000 each accident
Uninsured/Under Insured Motorist Coverage Auto #1: $20,000 each person $40,000 each accident $25,000 each person $50,000 each accident $50,000 each person $100,000 each accident $100,000 each person $300,000 each accident
Uninsured Motorist/Property Damage Auto #1: NO COVERAGE $15,000 each accident $25,000 each accident
Comprehensive Deductible Auto #1: No Coverage $1000 $750 $500 $250 $100 $50 $0
Collision Deductible Auto #1: No Coverage $1000 $750 $500 $250 $100
Medical Coverage Auto #1: No Coverage $1,000 $2,000 $5,000 $10,000
Towing Coverage Auto #1: Yes No
Amount of Towing coverage per disablement: No Coverage $25 per disablement $50 per disablement
Car rental reimbursement Auto #: Yes No

Auto Description Auto # 2

Auto #2 Year, Make, Model and Body Style:
Vehicle Identification Number:
Annual Mileage Driven:
Number of miles driven to work or school one way:
Alarm Auto #2: YES NO
Alarm Type Auto #1. Give a short description of alarm:

Anti-Lock Brakes Auto #2: Y N
Driverside Airbag Auto #2: Y N
Passengerside Airbag Auto #2: Y N
Is Auto #2 Used For Business: Y N

Coverage Limits Auto # 2

Liability for Bodily Injury, Auto#2: $20,000 each person $40,000 each accident $25,000 each person $50,000 each accident $50,000 each person $100,000 each accident $100,000 each person $300,000 each accident
Property Damage, Auto #2: $15,000 each accident $25,000 each accident $50,000 each accident $100,000 each accident
Unins./Under Ins. Motorist Auto #2: $20,000 each person $40,000 each accident $25,000 each person $50,000 each accident $50,000 each person $100,000 each accident $100,000 each person $300,000 each accident
Uninsured Motorist/Property Damage Auto #2: NO COVERAGE $15,000 each accident $25,000 each accident
Comprehensive Deductible Auto #2: No Coverage $1000 $750 $500 $250 $100 $50 $0
Collision Deductible Auto #2: No Coverage $1000 $750 $500 $250 $100
Medical Coverage Auto #2: No Coverage $1,000 $2,000 $5,000 $10,000
Towing Coverage Auto #2: Yes No
Amount of Towing coverage per disablement: No Coverage $25 per disablement $50 per disablement
Car rental reimbursement Auto #2: Yes No

Misc. Information

Anyone in household with suspended or revoked license? Yes No
Is there anyone residing in the household under 25 years of age? Yes No

For more than two autos/drivers, please complete another form and leave a comment to that effect in the comment section

Enter any comments, clarifications, explanations, and/or questions here:

SDG INSURANCE AGENCY