insurance graphic

You may just want to change agents - Check with us before you buy or renew!

insurance graphic

Low Cost
Insurance for
North Carolina
Residents!


Call Us for a
RUSH Quote.
We can place
Coverage
INSTANTLY!

 
Or, Get A FREE
Quote On-Line

 
 
Auto Insurance
"D.W.I." Insurance
Antique & Classic Car
Cycle & 4 Wheeler
Homeowners
Builder's Risk
Modular/MobileHome
Businessowners
Worker's Comp
Commercial Auto
Contractor Liability
Recreational Vehicle
Boat Insurance
Life Insurance
Short Term Health
Hospital Insurance
Medicare Supplements
Disability Insurance

 
Contact Us
 
 
E-Mail:
apbenfield@aol.com

Phone:
Toll Free:
1-866-632-6458
Direct Line:
1-828-632-6505

Fax:
1-828-632-0172

Mailing Address:
78 East Main
Avenue
Taylorsville,
NC 28681

Insurance
License #:

237-68-0393

Meet Our Staff!


For Your
Convenience,
We Accept:

Don't forget to ask about our "10+10" Insurance Discount! That's 10% off your Home and Auto Insurance when we write both policies. DOUBLE Your Discounts NOW!

insurance
 
Disability Income
Insurance Quotation Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Street Address:
City:
State: (Must be North Carolina)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Currently Employed?
Yes No
 
Disability Ins. Currently?
(If yes, list carrier, and # of years
continuous. If none, type N/C)


UNDERWRITING INFORMATION
 
Insured Name: Birthdate:
Insured Height: Insured Weight:
Insured Occupation: Sex (M/F):
Monthly Wage
(gross income)
$ Do You Smoke?
Yes
No
 
In Dollars, How much of
a monthly benefit do you want?

$
 
When Do You Want Your
Disability Policy to Begin?
 
Choose Wating Period:
(The time that will elapse before your disability payments begin)
30 Days
60 days
90 days
180 days
365 days
 
Choose Benefit Period:
(The amount of time you will receive benefits for)
1 Year
2 Years
3 Years
5 Years
To Age 65
 
Tell Us What You Want MOST in your Disability Plan, or list any other Remarks here:


Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone!

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me My
Disability Insurance Quote NOW!


Help Us Fight Spam! Type the Numerical Code you see at right, into the empty text box on the left, so we know you are a human. Thanks for your help!

Enter code at right, here:
Web Form Protection Code
reload image

Click Button Below When Done

Please Click Only Once . . . May take up to 30 seconds!

 
Terms of Use/Privacy Notice/Copyright Info. No. Carolina Insurance Online since: September 2,000.
Please report site-related technical problems to: apbenfield@aol.com    2008 Insurance-Web-Sales
 
insurance graphic