First Casualty Insurance Group, Inc.

Auto Quote

In order to provide you with a quote and to determine your eligibility for our programs that we offer through various carriers, our agency and/or companies we represent may use information contained in credit, MVR reports, insurance loss history, and other various consumer reports. In order to provide you with a quote, our carriers may also develop a credit-based insurance score using these reports and sometimes this is accomplished by using a third party. For additional information on collection and disclosure of personal information, and your right to see and have the opportunity to correct any personal information in your files, please contact our office. The reports provide us and/or our carriers with information that assists with determining your eligibility for insurance and the final price you are charged. By completing these forms, you agree to this process in making a request for a quote.

Form:Auto Insurance Quote

Auto Insurance Quote

Contact Information

Full Name:		Day Telephone:
Street Address:		Eve Telephone:
City, State & Zip:		Fax:
E-Mail Address:		Best Time To : Reach You
# of years @ Current Address:
Do You Own a Home?:

Current Insurance Information

Insurance Company Name: (NOT* Insurance Agency/Broker)*
Policy Exp. Date:	(mm/dd/yy)	Premium Amt:
Term:		How long with current?:

Vehicle Information

	(List all cars owned or leased)
Vehicle 1:	Year	Make/Model	Vin #

	Yearly Mileage	Usage	Alarm


Vehicle 2:	Year	Make/Model	Vin #

	Yearly Mileage	Usage	Alarm


Vehicle 3:	Year	Make/Model	Vin #

	Yearly Mileage	Usage	Alarm


Vehicle 4:	Year	Make/Model	Vin #

	Yearly Mileage	Usage	Alarm

Any Custom equipment on vehicles?: (if YES, give their value & indicate which vehicle)

Coverage Information

Liability limits for bodily injury & : property damage
Uninsured Motorist Bodily Injury:

Deductibles

	Comp. & Collision	Towing coverage	Rental Reimb.
Vehicle 1:
Vehicle 2:
Vehicle 3:
Vehicle 4:

Driver Information

Driver 1
Name:		Sex:
DL # :		Marital Status:
Date of birth:		Driver's Education?:
Years Licensed:		Defensive Driving:
Occupation:		Good Student:
Driver 1 SS#:		SR 22 filing?:
Driver 2
Name:		Sex:
DL # :		Marital Status:
Date of birth:		Driver's Education?:
Years Licensed:		Defensive Driving:
Occupation:		Good Student:
Driver 2 SS#:		SR 22 filing?:
Driver 3
Name:		Sex:
DL # :		Marital Status:
Date of birth:		Driver's Education?:
Years Licensed:		Defensive Driving:
Occupation:		Good Student:
Driver 3 SS#:		SR 22 filing?:
Driver 4
Name:		Sex:
DL # :		Marital Status:
Date of birth:		Driver's Education?:
Years Licensed:		Defensive Driving:
Occupation:		Good Student:
Driver 4 SS#:		SR 22 filing?:

Accidents / Violations in the last 5 years?


	Driver 1	Driver 2	Driver 3	Driver 4
Minor violations - speeding,: turn, stop sign, red light, etc
Accidents - non chargeable:
Accidents - chargeable:
Chargeable Accident: Cost($)
Major violations - drunk: driving, reckless, hit and run, etc.

Any additional comments or information
that might be helpful in your quote

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

Enter the security code you see above. Code is NOT case sensitive.*

Have questions or concerns about your insurance?

We can help. Call 1-800-352-3416 For a quick quote, call us today!

We currently provide insurance services in:

North Carolina
South Carolina
Virginia