Carolina Insurance Group
Of Kernersville


Property & Casualty Insurance Specialists

Nationwide Insurance and my agency have a privacy policy to protect your personal information.  I will include a copy of Nationwide's Privacy Statement when I give you the quote.  Prior to issuing a policy, Nationwide verifies loss history  and credit history using consumer reports to provide an accurate and determine your eligibility.  You have a right to access and correct all personal information collected.

Now I am going to ask some questions that could provide a discount or affect eligibility.

Name
Current Address
City, State, Zip Code
Social Security Number
DOB / Marital Status |
Spouse or Co-Insured Information
Name
Address
City, State, Zip Code
Social Security Number
DOB / Marital Status |
Property Information
Street
City, State, Zip Code
Specific Information About Property
Closing Date
Year Built
Occupancy
Type Home
Within 100' Fire Hydrant
Within 5 Miles of Fire Department
Fireplace in home?
Number of bedrooms?
Square Footage
Basement / Finished percentage /
Attached garage
Stories
Alarm System
Pets
Current auto insurance carrier
Would like quote?
Interested in home/car discount?
Flood insurance quote?
This is a conditional quote based on preliminary information you have provided.  The amount of insurance we have quoted may need to be adjusted based on prior claims, credit or inspection of your home.  Do you have any questions?  If so, type in the space provided below.  Be as thorough and complete as possible, using as much space as needed