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 Disability Insurance 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.
Contact Information
Company Name
 *
Name
 *
Title
 *
Contact Name (if different)
Title
Street Address
 *
City
 *
State
 *
Zip
 *
Email
Phone
 *
Fax
 
Coverage Desired
Fill in all that you would like to see illustrated
Monthly Benefits #
Elimination Period (period of disability before benefits start).
1 week
2 weeks
4 weeks
13 weeks
26 weeks
52 weeks
Length of Benefits
6 months
1 year
2 years
5 years
10 years
Age 65
 
Personal Information
Name 1
Date of Birth
Monthly Benefits
Gender
Tobacco Use
Height
Weight
Have you (they) had any of the following health conditions?
Heart
Cancer
Diabetes
High Blood Pressure
Occupation
Years of experience
Exact Duties
Name 2
Date of Birth
Monthly Benefits
Gender
Tobacco Use?
Height
Weight
Have you (they) had any of the following health conditions?
Heart
Cancer
Diabetes
High Blood Pressure
Occupation
Years of Experience
Exact Duties
Name 3
Date of Birth
Monthly Benefits
Gender
Tobacco Use?
Height
Weight
Have you (they) had any of the following conditions?
Heart
Cancer
Diabetes
High Blood Pressure
Occupation
Years of Experience
Exact Duties
 
Are there any past or current health problems? If yes please list name and provide details
Is anyone currently taking any medications? If yes please list name and provide details
Has anyone been declined for health insurance? If yes please list name and provide details
Any additional comments or information that might be helpful
 
By completing this form you are acknowledging your understanding of and agreement with the following terms:
1. No coverage of any kind is bound or implied by submitting information via this online form.
2. 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.
3. We will not distribute information to other parties other than for insurance underwriting purposes.
4. We value your privacy. Every precaution has been taken to insure your privacy and security.
5. By submitting this form you agree to release us from any liability should this information be accidentally viewed by others.
Security code:
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Call 1-800-352-3416

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We currently provide insurance services in: 
  • North Carolina
  • South Carolina
  • Virginia

    Please note: Changes to policies via this website are not effective or binding until you, or any party involved, receive official notification from your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

    First Casualty Insurance Group, Inc.
    190-A Turner Street
    Southern Pines, NC 28387
    1-800-352-3416
    fciginfo@fcignc.com
     
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