MEDICAR LICENSE APPLICATION

We have provided information and a copy of the State of Illinois’s Medicar License Application, If you have any questions we have customer service people ready to answer your questions. 312-664-8088

MEDICAR LICENSE APPLICATION

BACP ACCOUNT #:_______________________

FULL NAME:_______________________________________

D. O. B: _______       S S #:  ________________________

HOME ADDRESS:______________________________________

CITY / STATE / _______________________________________

ZIP CODE:__________________________________________

HOME PHONE #:___________________________________

Email : ______________________________________

DRIVER’S #:______________   State :______________

BUSINESS LOCATION INFORMATION

DBA NAME: _________________________________________

ADDRESS:__________________________________________

CITY / STATE _______________________________________

ZIP CODE:________________________________________

BUSINESS PHONE #: _______________ FAX ______________

CONTACT NAME:____________________________

E-MAIL- ADDRESS: _________________________

CELL PHONE #: ____________________________

PROVIDE A 24 HR. EMERGENCY CONTACT PHONE #: ____________________

PROVIDE A BUSINESS MAILING ADDRESS
(if different than the Business Location Address):

____________________________________________________

IF YOU PREFER TAX MAILINGS TO BE SENT TO A DIFFERENT LOCATION, PROVIDE ADDRESS:

___________________________________________________________

Medicar License Application QUESTIONS

Have you ever had ownership interest in any state or city license which was suspended or
revoked? Yes / No _____

Have you ever had any state or city licenses suspended or revoked? Yes / No ________

Have you been convicted of a crime within the last ten (10) years? Yes / No _________

List any pending criminal cases you are involved in. ______________________________

Do you have any other Public Vehicle licenses within the City of Chicago? Yes / No _____

If yes, give the date of the suspension or revocation. _________________________

If yes, indicate the license type. _________________________

 

Have you been convicted of a crime within the last ten (10) years? Yes / No ________

List any pending criminal cases you are involved in.

Do you have any other Public Vehicle licenses within the City of Chicago? Yes / No _____

If yes, give the date of the suspension or revocation. _________________________

If yes, indicate the license type. _________________________

If yes, please write the defendant’s name. _________________________

Please indicate the type of offense, the date, city and state of conviction.

Please write the defendant’s name. _________________________

Please indicate the type of offense, the next court date, and court where pending.

If yes, list the license type(s) and license number(s). _________________________

VEHICLE INFORMATION

VEHICLE 1:                                                       PV#__________

VIN: _______________________             

Year: _______     Make: ___________________

Model: ________     Capacity: _____        Color: _________

Vehicle Type (Circle One): Sedan   SUV    Stretch Other            State License Plate #: ______

Has this vehicle been converted by a qualified vehicle modifier? If yes, attach certificate. Yes/No

VEHICLE 2:                                                PV#___________

VIN: _______________________             

Year: _______     Make: ___________________

Model: ________     Capacity: _____        Color: _________

Vehicle Type (Circle One): Sedan   SUV    Stretch Other            State License Plate #: ______

Has this vehicle been converted by a qualified vehicle modifier? If yes, attach certificate. Yes/No

VEHICLE 3:

VIN: _______________________             

Year: _______     Make: ___________________

Model: ________     Capacity: _____        Color: _________

Vehicle Type (Circle One): Sedan   SUV    Stretch Other            State License Plate #: ______

Has this vehicle been converted by a qualified vehicle modifier? If yes, attach certificate. Yes/No

(YOU MAY DUPLICATE THIS PAGE AS NEEDED FOR ADDITIONAL VEHICLES)

INSURANCE INFORMATION

NAME OF INSURANCE AGENT :_________________________________________________

ADDRESS OF AGENT:_________________________________________________

PHONE NUMBER OF INSURANCE AGENT:_______________________________________

NAME OF INSURANCE COMPANY:____________________________________________

REQUIRED DOCUMENTS

*If operating with a DBA, provide the Assumed Name Certificate from the Cook County Clerk’s Office.

*Certificate of Insurance.

*Original titles for all vehicles.

*If vehicles are purchased as Used, provide a Vehicle History Report.

*If you do not own the vehicle(s), provide the lease agreement(s).

*Original State Inspection forms for all vehicles.

*City Stickers for all vehicles.

*Provide a valid lease for the business, or proof of property ownership.

*Must complete an Indebtedness Affidavit.

Urban Insurance has been in business since 1961, We have decades of experience working with Non-emergency medical transport companies. We understand the coverage Medicar providers need, and our outstanding customer service has earned us an A+ rating from the Better Business Bureau. When we prepare a quote for you, we compare plans and rates across different companies to find the best possible coverage at the lowest price. One way we get the lowest price is to ensure that we ask for every applicable discount (we’ve got a long list). And, when you call us – you’ll be connected to a living, breathing person. Go ahead – try it now.

(800) 680-0707 
or Click Here to complete an Application for Medicar Insurance.

City of Chicago
Department of Business Affairs
and Consumer Protection
Public Vehicle Operations Division
2350 West Ogden Avenue, 1st Floor
Chicago, Illinois 60608
(312) 746-4200
(312) 746-9406(FAX)
(312) 744-1944(TTY)
www.cityofchicago.org

Medicar License Application

Urban Insurance Agency 800 W Huron St Ste 301 ChicagoIL   60642 
(312) 664-8088  Fax # 312-664-7193      Additional Insurance Information


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