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THE SMITH FIRM & AGENCY
QUICK QUOTE FORM
We're DELIGHTED to have the opportunity to provide you with quotes for you specific insurance needs. With access to over 70 insurance carriers we're 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/Renters
Loan Officer, Realtors, Processor
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Indicate Purchase Type
*
Refinance
New Purchase
Renters
Closing Date
*
-
Month
-
Day
Year
Date
Previous Address (Needed by Underwriter for Claims Submitted)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mortgagee
Please Select
NFM, Inc dba NFM Lending ISAOA/ATIMA 1190 Winterson Rd., Suite 300 Linthicum, MD 21090
other
Other Mortgagee (Please Include Address (P.O. Accepted))
Loan Amount
*
Loan Number
*
Driver License Number
*
State of the License
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
Marital Status
*
Please Select
Single
Divorced
Married
Separated
Widowed
Permanent Domestic Partner
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Cellphone Number
*
E-mail
*
example@example.com
Other Phone Number
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
Name of the Spouse
*
First Name
Last Name
Spouse Driver License Number
*
Spouse State of the License
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
Spouse Gender
*
Male
Female
Spouse Date of Birth
*
-
Month
-
Day
Year
Date
Spouse Cellphone Number
*
Spouse Other Phone Number
Spouse E-mail
*
example@example.com
Spouse 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
Resident Type
*
Please Select
Rent
Own Home
Live w/Parents or other
Own Condo
Own Mobile Home
How Many Vehicles Are We Quoting
*
Please Select
NONE
1
2
3
more than 3
What is the status of the vehicle
*
Please Select
Financing (with Lien Holder)
Own (No payments owed)
Lease
Make of the Car
*
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 the Car
*
Seperate Multiple Vehicles with a COMMA (,)
VIN#
*
17 characters
How Long Have You Owned This Vehicle
*
Please Select
Less Than 1 year
1-3 Years
5 years or more
Have any drivers had any accidents, violations or claims during the past 5 years?
*
Yes
No
Incident Type
*
Please Select
No accidents - No claims
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
Make of the 2nd Car
*
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
What is the status of the 2nd vehicle
*
Please Select
Financing (with Lien Holder)
Own (No payments owed)
Lease
Year & Model of the 2nd Car
*
Seperate Multiple Vehicles with a COMMA (,)
VIN#
*
17 characters
How Long Have You Owned This Vehicle
*
Please Select
Less Than 1 year
1-3 Years
5 years or more
Have any drivers had any accidents, violations or claims during the past 5 years?
*
Yes
No
Incident Type
*
Please Select
No accidents - No claims
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
Make of the 3rd Car
*
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
What is the status of the 3rd vehicle
*
Please Select
Financing (with Lien Holder)
Own (No payments owed)
Lease
Year & Model of the 3rd Car
*
Seperate Multiple Vehicles with a COMMA (,)
VIN#
*
17 characters
How Long Have You Owned This Vehicle
*
Please Select
Less Than 1 year
1-3 Years
5 years or more
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
Which Car (if the Mate Drives) is There Primary Vehicle
If there's only 1 Car, type "SAME"
List Other Vehicles Here (Make & Vin#)
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
State Insured/Prospecting to be Insured
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
If Occupation not Listed, Please List Occupation
*
How do you hear about us?
Maryland Premier Tag & Title
Uber Driver Flyer
Flyer
Referred (if known)
Internet/Website
Insurance Agent (if known)
Realtor/Loan Officer (if known)
Name the Person/Business who Referred You | Insurance Agent | Realtor/Loan Officer
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