Higgins Insurance Agency, Inc
5252 W Irving Park Road Chicago Il 60641
Office: (773) 286-6666 Fax: (773) 286-0228
E-mail: higginsauto @ sbcglobal.net


Auto Insurance Quote Request (Illinois residents, for new business only)
If you are currently insured through Higgins Insurance Agency, Inc contact a
representative at (773) 286-6666 to request changes to your existing policy.
Vehicle Owner Information
Owner's Name:
Street Address:
City: State: Zip Code:
Daytime Telephone Number: (Where we may contact you between 9am - 5pm)
E-mail Address:
Referred By:
Vehicle Information
Vehicle 1 Year: Make 1: Model 1:
Vehicle Identification Number 1 (VIN): Coverage 1:
Vehicle Usage 1:
Vehicle 2 Year: Make 2: Model 2:
Vehicle Identification Number 2 (VIN): Coverage 2:
Vehicle Usage 2:
Vehicle 3 Year: Make 3: Model 3:
Vehicle Identification Number 3 (VIN): Coverage 3:
Vehicle Usage 3:
Driver Information
Driver 1 Name:
Date of Birth Driver 1: Gender 1: Marital Status 1:
Driver's License Status 1: Illinois License? 1:
SR-22 Filing Required 1?: If Yes, Reason 1:
List Accidents, Tickets Or Suspensions Within Past
36 Months With Dates:
Driver 2 Name:
Date of Birth Driver 2: Gender 2: Marital Status 2:
Driver's License Status 2: Illinois License? 2:
SR-22 Filing Required 2?: If Yes, Reason 2:
List Accidents, Tickets And Suspensions Within Past
36 Months With Dates 2:
Driver 3 Name:
Date of Birth Driver 3: Gender 3: Marital Status 3:
Driver's License Status 3: Illinois License? 3:
SR-22 Filing Required 3?: If Yes, Reason 3:
List Accidents, Tickets And Suspensions Within Past
36 Months With Dates 3:
Preferred Method Of Contact:

SUBMIT FORM AND A REPRESENTATIVE WILL CONTACT YOU DURING BUSINESS HOURS.
MON - FRI 9AM - 5PM OR SAT 9AM - 12PM

OR FOR IMMEDIATE ASSISTANCE CALL (773) 286-6666