Get a Quote Leave me blank for Insurance Quote. When filling out this form, please have your present policy available. During this process please DO NOT click back in your browser. Fields with an (*) are required. Step 1 Step 2 First Name * Last Name * Gender * Female Male SSN# * Date of Birth * Marital Status * Married Single Occupation * Mailing Address * City * State * - Choose a State - - Choose a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Preferred Phone * Email Best way to contact me * Phone Email Drivers License Number * Are you currently a member of UICCU? * Yes No Spouse Information Spouse First Name * Spouse Last Name * Spouse DOB * Spouse Gender * Female Male Spouse Occupation * Spouse SSN * Spouse Driver's License Number * Which products are you interested in? Select all that apply: * Auto Auto Insurance Quote Information Vehicle 1 Year * Vehicle 1 Make * Vehicle 1 Model * Vehicle 1 VIN Add another vehicle +- Vehicle 2 Year * Vehicle 2 Make * Vehicle 2 Model * Vehicle 2 VIN Add another vehicle +- Vehicle 3 Year * Vehicle 3 Make * Vehicle 3 Model * Vehicle 3 VIN Add another vehicle +- Vehicle 4 Year * Vehicle 4 Make * Vehicle 4 Model * Vehicle 4 VIN Add another vehicle +- Vehicle 5 Year * Vehicle 5 Make * Vehicle 5 Model * Vehicle 5 VIN Number of Additional Drivers Other Than Spouse (0 - 3) * Additional Driver 1 Info Driver 1 First Name * Driver 1 Last Name * Driver 1 DOB * Driver 1 Gender * Female Male Driver 1 SSN Driver 1 Driver's License Number Driver 1 Relationship to Insured * Additional Driver 2 Info Driver 2 First Name * Driver 2 Last Name * Driver 2 DOB * Driver 2 Gender * Female Male Driver 2 SSN Driver 2 Driver's License Number Driver 2 Relationship to Insured * Additional Driver 3 Info Driver 3 First Name * Driver 3 Last Name * Driver 3 DOB * Driver 3 Gender * Female Male Driver 3 SSN Driver 3 Driver's License Number Driver 3 Relationship to Insured * Home Home Insurance Quote Information Have you lived at your current address for 3 years or more? * Yes No Prior Address * Do you own any pets? * Yes No Breed of pet *for owned home info Is there any bite history? * Yes No Do you have any of the following? (Select at least one) * Pool Hot tub Trampoline Wood stove Fuses Asbestos siding None of these What year was your roof last replaced? * Life Life Insurance Quote Information Please choose one * Term Whole Life How much life insurance do you need? * What is your height and weight? * Height Weight Do you use tobacco? * Yes No What kind of tobacco do you use? * Cigarettes Smokeless Tobacco Do you have any medications that you take regularly? * Yes No An agent will contact you for additional information. Business Business Quote Info Type of business * Years of experience * Website Health Health Quote Info Do you use tobacco? * Yes No What kind of tobacco do you use? * Cigarettes Smokeless Tobacco Renters Renters' Quote Info Have you lived at your current address for 3 years or more? * Yes No Previous Address * Do you own any pets? * Yes No Breed of pet *for rental home info Is there any bite history? * Yes No How much personal property coverage would you like? * Other Product Other Quote Info Check at least one. * Umbrella Cycle Recreational Vehicle Boat Rental Property Other Quote Please specify. * How did you hear about us? Billboard Newsletter Website Direct Mail Radio Word of Mouth UICCU Employee Other/Not Listed Continue Reset Step 1 Step 2 « Back to Applicant Information Please Read and Signify That You Understand This Important Disclosure The information contained herein is provided for general informational purposes and is not intended to be a contract, nor is the information a complete description of all terms, conditions, and exclusions applicable to the products and services described. This does not constitute an offer of coverage or the purchase of insurance. No coverage may be added, changed, or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by UICCU Insurance in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company. To better serve you and to be able to offer you an accurate quote, UICCU Insurance will need to collect information from consumer reporting agencies, such as driving record, claims, and credit history reports, and may need to share certain information with qualified third party associates. UICCU Insurance will not sell customer information or allow those who are doing business on your behalf to use our customer information for their own marketing purposes. Future reports may be used to update or renew your insurance. I have read and understand the above message * Submit There was an error submitting the form Thank you for your interest! An agent will contact you within 2 business days.