Carter & Company, L.L.P.

(If not in Texas, please click here to view a list of states in which we currently have non-resident licenses.  If your state is not listed then we would not currently have a market for you.)

Automobile Insurance Quote Form
For the fastest and most accurate automobile insurance quote, please provide as much information possible
  in the form below. This information will be kept confidential and will be used for quote purposes ONLY!

General Information
First Name:
Last Name:
Address:
City:   State:    ZIP:
County:   Email:
*Social Security Number
*Required for credit check by
insurance companies:
Phone Day:              Night:
Best time to call:   AM   PM
Current Auto Insurance Company (not agency):
Company Name:
Policy Exp. Date: / /
Premium: $
Term: 6 Months   1 Year   Other  
Current Liability Limits
Current Personal Injury Protection Limits
Current Uninsured
Motorist Limits
Current Comp and
Collision Limits
Any Other Current Coverages
Vehicle Information:
(include all cars you or your family members own or lease)
Car #1 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
19
Name of Title Holder
 Annual Mileage
 Drive to school, work Yes   No

Drive for pleasure Yes   No
# of miles (one way):

Car equipped w/ airbags?
Yes   No
Anti-theft devices?
Yes   No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:
Car #2 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
19
Name of Title Holder
 Annual Mileage
 Drive to school, work, station? Yes   No
# of miles (one way): 		Car equipped w/ airbags?
Yes   No
Anti-theft devices?
Yes   No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:
Car #3 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
19
Name of Title Holder
 Annual Mileage
 Drive to school, work, station? Yes   No
# of miles (one way): 		Car equipped w/ airbags?
Yes   No
Anti-theft devices?
Yes   No
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:
Driver Information:
(including all licensed drivers in your household)
Driver's Name Occupation Relation
to you		 Date of birth
(Mo/Day/Yr)		 Male/
Female

M / F

 Married/
Single

M / S

 Completed # of Yrs.
Licensed		 % of Vehicle Use
Drivers
Education
Course		 Accident
Prevention
Course		 #1 #2 #3
Self M
F		 M
S		 Y
N		 Y
N
Self M
F		 M
S		 Y
N		 Y
N
Self M
F		 M
S		 Y
N		 Y
N
Self M
F		 M
S		 Y
N		 Y
N
Must add to:   100% 100% 100%
Driver History
If you answer "yes" to any of the following questions below,
please explain in the space provided:

Has any driver listed:

1. Been convicted of any moving traffic violation in the past 3 years?
    Yes   No
    If yes, please answer the following:

Driver Date Type of Conviction Time Fines Speed
Over Limit
// $ MPH
// $ MPH
// $ MPH
// $ MPH
// $ MPH

2. Had his/her license suspended or revoked?
    Answer only if "yes":

Driver Suspended Revoked
Yes Yes
Yes Yes
Yes Yes
Yes Yes

3. Been convicted of driving under the influence of alcohol or drugs?
    Answer only if "yes":

Driver Alcohol Drugs
Yes Yes
Yes Yes
Yes Yes
Yes Yes

4. Been involved in any accidents, regardless of fault, in the past 5 years?
    Yes   No
    If yes, please answer the following:

Driver Date Cost Fines Injuries At Fault Time Description
// $ $ Y
N		 Y
N
// $ $ Y
N		 Y
N
// $ $ Y
N		 Y
N
// $ $ Y
N		 Y
N
Additional Comments:
Please give any additional comments about the coverage you desire:

*See our Privacy Policy

 

Thank you for your time in submitting this automobile quote form. One of our representatives will respond to your submission as soon as possible!

 

 

 

Send mail to info@cartercompany.com with questions or comments about this web site.