CLOSING TICKET
Please complete for closing client's insurance policy
Is this PERSONAL LINES or COMMERCIAL LINES Insurance?
Personal Lines
Commercial Lines
Unsure
Personal Named Insured
*
First Name
Last Name
Commercial Named Insured
Commercial Insurance
Additional Insured(s)
If applicable. Please use comma between additional names.
Client Email
*
example@example.com
Client Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Policy Effective Date / Closing Date
*
-
Month
-
Day
Year
Desired Policy Start Date
New Insurance Carrier Name
How is the Home Insurance Paid?
Please Select
Escrow / Mortgage Company
Directly by Insured
Typically, insurance premiums are escrowed and paid when due, however not always the case.
Mortgagee Company
Legal Name of Company
Mortgagee Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Loan Number
Auto Lienholder?
Yes
No
Auto Lienholder / Bank Name
Auto Lien Holder
Auto Lienholder Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preference of Insurance Payment (Auto)
*
Please Select
Monthly
Quarterly
6 months (if applicable)
Annual
N/A - only if a HOME insurance policy
Payment Options
Preferred Method of Payment - (If monthly, then MUST be ACH)
*
Credit Card
Debit Card
ACH
Other
Name on the Banking Account
*
Client Routing #
*
Source of Payment
Client Account #
*
Source of Payment
Card Information
Anything important to note? If so please comment below.
Submitted By:
*
Your Name
Your Email
*
Your Email Address
Referred By
*
If someone directed you to GJIG, please list their name above. If not, just put N/A
Submit
Should be Empty: