Pinckney-Carter Insurance Company
One of South Carolina's Oldest Personal Independent Carriers 
email: info@pinckneycarter.com
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FREE QUOTE FORM

INFORMATION RELEASE AGREEMENT

As a part of the application process in obtaining the insurance coverage you are requesting from the Pinckney-Carter Company and/or its agents may order one or more consumer reports. A consumer report may contain information on credit history, medical conditions, driving record, criminal activity and hazardous sports, among other things.

Under the Fair Credit Reporting Act, the insurance company and/or its agents may review consumer reports to evaluate anyone who applies for insurance. In the event that coverage is denied to you based wholly or partly on information in a consumer report you will be notified of this fact, and given the name and address of the consumer reporting agency making the report.

In consideration of the above, your initals below acknowledges your release for the insurance company and/or its agents to order one or more consumer reports in your name.
Initial here to accept the information agreement above and continue.
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To inquire about home owners' insurance click here.
For auto insurance fill out the form below.
DRIVER #1
 
Vehicle #1
First Name
DOB
 
Year
Middle Name
Sex:
M
 
Make
F
Last Name:
Home Ph
 
Model
:Suffix
Work Ph
 
VIN
SSN:
     
Pleasure
Drivers Lic No
State:
 
Primary Use
Business
      To/From work
Current Policy Information for vehicle #1
Current Address:
The space below is to provide any notes about this policy that you would like to include.
Previous Address:
Current Carrier:
Policy Number

DRIVER #2

 
Vehicle #2
First Name
DOB
 
Year
Middle Name
Sex:
M
 
Make
F
Last Name:
Home Ph
 
Model
:Suffix
Work Ph
 
VIN
SSN:
     
Pleasure
Drivers Lic No
State:
 
Primary Use
Business
      To/From work
Current Policy Information for vehicle #2
Current Address:
The space below is to provide any notes about this policy that you would like to include.
Previous Address:
Current Carrier:
Policy Number
REQUESTED COVERAGE AMOUNTS
  15,000/30,000/10,000     $250
  25,000/50,000/25,000
Deductibles:
$500
Requested Liability Limits:
50,000/100,000/50,000     $1000
100,000/300,000/50,000      
250,000/500,000/50,000     $1000
100,000 Single Limit Medical Payment: $2000
  300,000 Single Limit       $5000
  500,000 Single Limit      
 
Would you like to cover towing?
Yes   No
Would you like to cover Car Rental?
Yes   No