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The information placed within this form shall be held strictly confidential by Dunamis Insurance Services & its representatives according to applicable state and federal law. Information shall not be sold and or distributed in any manner without applicants prior and specific written consent, and shall only be used to help secure insurance as requested by the applicant. Quoted rates are not guarantees of coverage. Neither Dunamis nor its representatives make guarantees of insurance coverage. Completion of this form shall not be considered an offer for insurance. Final rates, classifications, determinations and approval for insurance are based solely on the applicants ability to meet the underwriting criteria of the company to which an application for insurance is made. For questions or concerns, please call (309)648-5351 or email
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