Auto Insurance Quote

(North Carolina Only)

This page provides you the opportunity to request an automobile quote on-line. In order to get a prompt, accurate quote we ask that you take your time to fill in this form completely. After we receive the quote request we will contact you via your desired method as soon as possible. To use this form, please click in each text box to type in the information and then use the TAB key or your mouse to select the next text box. If an item doesn't apply to you, leave it blank and the system will ignore it.

Name
Address
City
State
Zip Code
Telephone Number
Fax Number
E-Mail Address

Vehicle Description

Vehicle #1 - (Year, Make & Model)
How is this car used?

Vehicle #2 - (Year, Make & Model)
How is this car used?

Vehicle #3 - (Year, Make & Model)
How is this car used?

Driver Information

First Driver Name		Date of Birth	--
	Sex Male Female	Marital Status
	Occupation/How Long?

Second Driver Name		Date of Birth	- -
	Sex Male Female	Marital Status
	Occupation/How Long?

Third Driver Name		Date of Birth	- -
	Sex Male Female	Marital Status
	Occupation/How Long?

Fourth Driver Name		Date of Birth	- -
	Sex Male Female	Marital Status
	Occupation/How Long?

Please list all traffic violations within 3 years and any accidents for all drivers listed above
(please include not-at-fault accidents)

Current Coverages-

Bodily Injury Liability Limit

Uninsured Motorist Liability Limit

Medical Payments

Comprehensive deductible

Vehicle #1

Vehicle #2

Vehicle #3

Collision Deductible

Vehicle #1

Vehicle #2

Vehicle #3

Towing Coverage Yes No

Rental Reimbursement Coverage Yes No

Safety Credits

Are any of your vehicles equipped with the following safety features?

Air Bags - Vehicle #
Automatic Seat Belts - Vehicle #
ABS Brakes - Vehicle #
Alarm System - Vehicle #

Additional Credits -	Do you own a home? Yes No
	If renting, do you have a renter's policy? Yes No

POLICY INFORMATION?

What company are you currently insured with?
What is the expiration date of your policy?
What is your current 6 month automobile premium?

Any other information you feel that is pertinent to your auto policy?

How would you like to receive your quotation?

By E-Mail, E-Mail address
By Fax, Fax Number
By Telephone, Preferred time, Phone number

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Colonial Insurance Agency - P.O. Box 490 - Hillsborough, NC - 27278 - (919) 732-2191 - info@colonial-agency.com