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
Telephone Number
Current Insurance |
Who Will Be Insured
Name / DOB / SSN / License
Name / DOB / SSN / License
Name / DOB / SSN / License
Name / DOB / SSN / License
Vehicle
Year / Make / Model / VIN / W/P / Ded
Year / Make / Model / VIN / W/P / Ded
Year / Make / Model / VIN / W/P / Ded
Year / Make / Model / VIN / W/P / Ded
Year / Make / Model / VIN / W/P / Ded
Coverage
Coverage Limits
Towing and Rental
Discount - Home / Affinity /
Accidents and violations
Please describe in detail
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 driving record.  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