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 Life 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.
Full name
 *
Street address
 *
City
 *
State
 *
Email address
Daytime telephone
 *
Evening telephone
Best time to contact you
Self
Name
 *
Date of birth
 *
Gender
Marital status
 *
Height (ie...5'6")
 *
Weight (lbs)
 *
Tobacco use
Have you ever been treated for
Cancer
Diabetes
Cardiovascular disorders
If yes please explain
Have your parents or siblings been treated for any of the following prior to age 60?
Cancer
Diabetes
Cardiovascular disorders
If yes please explain
List any medications you are taking. Please include dosage and frequency.
List any health problems you think might impact the rate
Have you had 2 or more moving violations in the past 2 years?
If yes please explain
Any DUI's in the past 5 years?
If yes please explain
Type of coverage
Amount of coverage
 *
Disability income
Children
Child 1 Name
Child 1 date of birth
Amount of coverage
Type of coverage
Child 2 Name
Child 2 date of birth
Amount of coverage
Type of coverage
Child 3 name
Child 3 date of birth
Amount of coverage
Type of coverage
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:
 *
Do not enter anything in this field:
* indicates a required field
 
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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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