THE SMITH FIRM & AGENCY
QUICK QUOTE FORM
I’m DELIGHTED to have the opportunity to provide you with quotes for you specific insurance needs. With access to over 50 insurance carriers I’m confident that we can tailor a plan that provides the exact amount of coverage you need at a price that fits your budget!
Products of Interests (Click ALL that apply)
*
Auto
Business
Commercial
Flood
Home
Specialty
Umbrella
Other
Name
*
First Name
Last Name
Gender
*
Male
Female
Cellphone Number
*
Other Phone Number
E-mail
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Resident Type
*
Please Select
Rent
Own Home
Live w/Parents or other
Own Condo
Own Mobile Home
Highest Educational Level
*
Please Select
Lower Than High School
High School
Vocational/Trade School Graduate
Some College
Associate Degree
Bachelor Degree
Masters Degree
Doctorate Degree
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How Many Vehicles Are We Quoting
*
Please Select
1
2
3
4
5
6
7
8
9
10 or more
Make of Cars(s)
*
Acura
Alfa Romeo
Aston Martin
Audi
Bentley
BMW
Buick
Cadillac
Chevrolet
Chrysler
Dodge
Ferrari
Fiat
Ford
Genesis
GMC
Honda
Hyundai
Infiniti
Jaguar
Jeep
Kia
Lamborghini
Land Rover
Lexus
Lincoln
Lotus
Maserati
Mazda
McLaren
Mercedes-Benz
Mini
Mitsubishi
Nissan
Polestar
Porsche
Ram
Rolls-Royce
Smart
Subaru
Tesla
Toyota
Volkswagen
Volvo
Year & Model of Car(s)
*
Seperate Multiple Vehicles with a COMMA (,)
VIN#
17 characters
Have any drivers had any accidents, violations or claims during the past 5 years?
*
Yes
No
Incident Type
Please Select
Accident - At Fault
Accident - Not At Fault
Compehensive - (OTC Claim)
Small Compehensive Claim
Minor Coverage Claim
No Payout Claim
Speeding - Less than 30 MPH over limit
Failute to Yield/Stop/Signal
Improper Driving /Other Minor Violation
Speeding - Over 30 MPH or more over limit
DUI/DWI
Reckless or Negligent Driving
Failure to stop after an accident
Driving on Suspended or Revoked License
Racing
Theft of a Vehicle/Criminal Use
Company/Business Name
*
Company/Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Line of Business
*
i.e. Education, Retail Sales, Law
Industry
*
Please Select
Attorney
Artisan Contractors
Auto Service/Repair
Cleaning/Janitorial
Habitational
Home Health Care
Institutional
Lawn Service/Landscaping
Manufacturing
Office
Other
Plumbers
Real Estate
Restaurant
Retail
Service
School Director/President/Owner
Tavern/Food Truck
Wholesale
Business Entity
Please Select
Partnership
LLC
Corporation
Individual/Sole Proprietor
Other
Year Established
*
Number of Employees
*
Annual Revenue
*
Business Website
Building Square Footage
Currently Have Business Insurance
Yes
No
Use Any Vehicle for Business
Yes
No
Franchise
Yes
No
How Many Years in Business
*
Premises Type
*
Please Select
Leased Premises
Home Based
Building Owned & Occupied
Estimated Annual Payroll
Marital Status
*
Please Select
Single
Divorced
Married
Separated
Widowed
Permanent Domestic Partner
Name
First Name
Last Name
Gender
*
Male
Female
Cellphone Number
*
Other Phone Number
E-mail
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Which Car (if the Mate Drives) is There Primary Vehicle
If there's only 1 Car, type "SAME"
State Insured/Prospecting to be Insured
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Policy Expiration (If Known)
-
Month
-
Day
Year
Date
Current Insurance Provider
*
Please Select
Farmers
Progressive
State Farm
Nationwide
Geico
USAA
Travelers
Liberty Mutual
Erie
AllState
Other
Not Insured
Current Monthly Premium
Are You Currently Employed
*
Yes
No
Retired
Self Employed
Occupation
*
Please Select
Accountant
Architech
Aviator
Dentist
Educator
Engineer
Farmers/Zurich
Fire Fighter
Law Enforcement
Lawyers/Judge
Librarian
Military
Other
Physician/Nurse
Police Officer
Real Estate Agent/Broker
Scientist
Veterinarian
Marketing Initiative
The Love Center
City of Hope at the Energy Centre
International Network of Churches, Ministries and Businesses
Manifested Glory Worship Center (Maryland)
Church of Atlanta Lighthouse
Abundance Life and Restoration Ministries International
Connect Church Raleigh
Changing Lives Ministries of Baltimore
WE OUR US Movement
New Generation Restoration C.C.
Bridge Network Covenant Fellowship
The Di Experience
Community Service Group
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