188 Industrial Dr.  #215
Elmhurst, IL  60126
800 801-1823  
630 617-9950 (fax)
Because we write with many
different companies, we must
review the provided information to
determine which company best fits
your needs.  We are not able to
provide instant quotes for this
reason.
Collector Auto Quote Request
First Name                                              Last Name
 
VEH 1









VEH 2







VEH 3









VEH 4
Street Address                                      
City                                                                                           State         Zip Code
EMAIL ADDRESS                                                              PHONE #     
  • Is your car used  primarily as secondary  
    transportation and not used for going to and from
    work?
  • Is your car garaged in a fully enclosed
    garage?
  • Are you willing to Exclude all drivers under the age
    of 26 that are in the household?
  • Do you have no more than 1 ticket or accident
    in the past 3 years ?
  • Do you have no more than 2 tickets or
    accidents in the past 5 years?
office for a quote.  Call 800 801-1823  to speak to a Quote office for a
quote.  
Call 800 801-1823  to speak to a Quote Specialist.  Call 800
801-1823  to speak to a Quote Specialist.  Specialist.  
YEAR           MAKE / MODEL                                                                 VALUE               
STOCK ?
         
YEAR           MAKE / MODEL                                                                 VALUE               
STOCK ?
         
YEAR           MAKE / MODEL                                                                 VALUE               
STOCK ?
         
YEAR           MAKE / MODEL                                                                 VALUE               
STOCK ?
         
DRIVER INFORMATION
NAME


NAME


NAME


NAME
DOB


DOB


DOB


DOB
VEHICLE INFORMATION
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