800 W Williams Street, Suite 231-C
Peakway Market Square
Apex, NC 27502
(919) 267-3063
ABC Insurance Agency is only licensed in the states of North Carolina & Pennsylvania.
PERSONAL AUTO QUOTE FORM
ALL FIELDS ARE REQUIRED FOR AN ACCURATE QUOTE
How did you hear about this website?
Name: Date of Birth
Name2: Date of Birth
Street Address:
City, State Zip: ,
If less than 3 years
Previous Street Address:
Previous City, State Zip: ,
Phone Number:
Email:
Do you currently have auto insurance?
Current Insurance Company?
Current BI Coverage limits? (Discount my apply)
Own or Rent? Interested in homeowners/renters insurance?
How many Motor Code Violations are in the household:
Date: Explanation
Explain Above:
Are there any moving/non-moving or other violations not listed above (including PJC's
in NC) that may show up on any driver in the household's MVR?
Date: Explanation
Explain Above:
How many auto claims have been filed in the household including windshields,
comprehensive claims, not at faults, etc.
Date: Explanation
Explain Above:
VEHICLES: Pleasure Distance
VIN Side Annual Commute to
Year Make & Model if known Alarm? Airbags? Miles Business Work
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
DRIVERS: Aprox.
License Date Vehicle
Name DOB Number Licensed Driven
List all other residents of household if not a driver listed above.
Name Relationship Age or DOB
CURRENT LIMITS
Bodily Injury
Property Damage
Uninsure/Underinsured
Medical Payment
Death Benefit (Y/N)
CURRENT COVERAGE
Other Extented
than Transportation
Collision Collision Towing Coverage
Deductable Deductable (Y/N) Amount per day
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
OTHER DISCOUNTS THAT MAY APPLY
SAFE DRIVER DISCOUNT
Has any driver in the household been involved in any accidents including
not-at-fault accidents in the past 5 years?
Has any driver in the household had any claims including comprehensive claims
on your auto insurance in the past 5 years?
Has any driver in the household had any violations (including PJC's in NC) in the past 5 years?
ADVANCE QUOTE DISCOUNT
Are you able to wait for 7 days for this policy to go into effect?
PAY PLAN DISCOUNT
Would you be willing to pay your premium in full or with in the first 60 days for a discount?
OTHER DISCOUNTS THAT APPLY
HOME/AUTO Multi-Policy Discount
LIFE/AUTO Multi-Policy Discount
Best Time to Reach You:
Comments
By saying "YES" in box to the right I give consent to order a credit based insurance score.
If any other answer than yes appears above, a quote will not be complete.
Phone: 919.267.3063
Fax: 866.453.9992
E-mail: agency@abc-insure.com
Address:
ABC INSURANCE AGENCY
800 W. Williams St, Suite 231-C
Apex, NC 27502