North Carolina Auto Insurance Quotes

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Your Name:

Mr. Mrs. Ms.

Address:

City:

County:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

e-mail Address:

Please answer the following questions based on the last 3 years.
Have you or any other drivers in your household...
been convicted of driving under the influence of alcohol or drugs?	Yes No
had your license suspended or revoked?	Yes No
been convicted for Hit and Run or Leaving the Scene of an Accident?	Yes No
received any speeding tickets or other moving violations?	Yes No
been involved in an accident where you or your insurance company made payments to another person?	Yes No
been involved in an accident where damage was caused by hitting a stationary object (Tree, curb, parked car, etc.)?	Yes No
Please indicate the total number of auto insurance claims involving you or other drivers in your household.

Driver(s) Information

Name	Birth Date	Gender	Marital Status	Good Student

Drives License Number

Drives License Number

Drives License Number

Drives License Number

Drives License Number

Vehicle Information

Year	Make	Model	Miles To Work One Way	4 Wheel ABS	Auto Belts, Airbags	2WD/ 4WD	Tons (Truck Only)	Security System

Coverage Information

Coverage Type	Auto 1	Auto 2	Auto 3	Auto 4
Bodily Injury
PD
UM
UIM
Medical
Comp Deductable
Coll Deductable
Towing
Rental Car
Stereo Value

Comments

**Due to the high cost of health care, cost of repairing and replacing vehicles and defending lawsuits, McLeod Insurance Agency, LLC strongly urges consumers to carry higher limits of liability insurance coverages than the North Carolina minimum requirements!!**