Stan Taylor Insurance Agency

Auto Insurance

Let us quote your North Carolina car insurance! Please fill in this form and submit it to us. We will contact you by the end of the next business day with a quote.

For the best quote available, please allow us to quote your homeowners insurance also.

*Name		*Home Phone
*Address		Work Phone
Address		Work Fax
*City		Email Address
*State		Own your home?
*Zip		Prefer contact by:
		Best time to call:

	*Driver 1	Driver 2	Driver 3
*Name:
Social Security Number:
*License #:
*State:
*Birth date:
*Gender:
*Marital Status:
Occupation
*Number of Tickets in last 3 yrs:
*Ticket Description:
*Number of Accidents in last 3 yrs:
*Accidents declared at fault:
*Accident Description:
*Amount Insurance Company Paid Out for Accidents:

Present auto policy with:
Present policy expires:

Is car driven to work or school?		If, so miles one way:
Is car used in business (excluding to and from work)?

	*Vehicle 1	Vehicle 2	Vehicle 3
*Year
*Make
*Model
Number of Doors
Number of Cylinders
*Comprehensive Deduct
*Collision Deduct
*Towing Coverage	Yes No	Yes No	Yes No
Transportation Expenses (rental car reimbursement)	Yes No	Yes No	Yes No

*Liability limit for all cars	*Bodily injury
*Liability limit for all cars	*Property damage

Any questions or comments?
How did you find out about Stan Taylor Insurance?

This is a request for a quotation only. No coverage will go in effect until bound by an insurance company.
In order to accurately quote your car insurance, a DMV report and credit check are required.

Disclaimer

Directions & Hours

Contact Information -
3826 Bland Road
Raleigh, North Carolina 27609
Telephone : 919-781-5300
Fax : 919-787-1896
Electronic Mail : webmaster@stantaylor.com