Form Center • Market Assistance Consumer Registration Form

Steps

1. Personal Information This section is complete This section is incomplete
2. Property Location This section is complete This section is incomplete
3. Mailing Address This section is complete This section is incomplete
4. Personal Residential Information This section is complete This section is incomplete

Personal Information

First Name*
Last Name*
Telephone*
Alternate Telephone
Email Address
SCDOI may release my email address to Agents and\or Insurance Companies*
1. Agree
2. Disagree
Best Method to contact*
Check all that apply
1. Telephone
2. Email
1. Mail
SCDOI may release my email address in response to public information requests
1. Agree
2. Disagree
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Property Location

Address*
Address 2
City*
County*
Zip*
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Mailing Address

Same as address entered above:
1. Yes
Address1
Address2
City
State
Zip
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Personal Residential Information

Type of Dwelling*
Construction Type*
Occupancy Type*
Square Footage*
Is property within city limits*
1. Yes
2. No
Amount of Insurance needed ($)*
Number of Stories
Disclaimer
SCMarketAssist.com is a free service sponsored by the South Carolina Department of Insurance (DOI) which helps South Carolina consumers find insurance. SCMarketAssist.com and the DOI need certain personal information to help you. Any information received and maintained by the DOI may be subject to release under the provisions of the South Carolina Freedom of Information Act (FOIA). Information deemed personal or afforded confidential treatment will be redacted before the information is released. Sharing this type of information to participate in SCMarketAssist.com program does not waive these confidentiality or privacy protections. If you would like more information about the type of information maintained by the Department, please consult the Department’s FOIA policy at
South Carolina Department of Insurance FOIA Policy
http://doi.sc.gov/123/Freedom-of-Information-Requests-FOIA
Access to and Correction of Personal Information
You may review or receive copies of information maintained by the Department about you subject to the S.C. Freedom of Information Act. You may access and correct information on your application. For more information about how to access and correct your insurance profile, please email the Office of General Counsel.
Email the General Counsel
http://legmail.doi.sc.gov
You will need your user ID and password to access and update information to your profile. The information you enter will be sent electronically to insurers and producers who have expressed an interest in participating in this program.

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1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Steps

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