Smith Agency Car/Home Insurance Quotation Form

1
Products of Interests (Click ALL that apply)* This field is required.
Auto
Business
Commercial
Flood
Home/Renters
Loan Officer, Realtors, Processor
2
Name* This field is required.
First Name
Middle Name
Last Name
3
Current Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Please Indicate Purchase Type* This field is required.
Refinance
New Purchase
Renters
5
Closing Date
Date
Month
Day
Year
6
Property Address (Property to be Purchased)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Mortgagee
Please Select
Please Select
NFM Lending, LLC ISAOA/ATIMA 1190 Winterson Rd., Suite 300 Linthicum, MD 21090
Fidelity Direct Mortgage, LLC ISAOA / ATIMA 438 North Frederick Ave, Suite 315 Gaithersburg, MD 20877
Fairway Independent Mortgage Corporation ISAOA/ATIMA 4201 Marsh Lane Carrollton, TX 75007
8
Other Mortgagee (Please Include Address (P.O. Accepted))
9
Loan Amount (If known)
10
Loan Number (If known)
11
Driver License Number* This field is required.
12
State of the License* This field is required.
Please Select
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
13
Marital Status* This field is required.
Single
Divorced
Married/Domestic Partner
Separated
Widowed
Permanent Domestic Partner
14
Date of Birth* This field is required.
Date
Month
Day
Year
15
Gender* This field is required.
Male
Female
16
Cellphone Number* This field is required.
17
Text Consent* This field is required.
18
Terms and Conditions* This field is required.
19
E-mail* This field is required.
example@example.com
20
Other Phone Number
21
Highest Educational Level
Lower Than High School
High School
Vocational/Trade School Graduate
Some College
Associate Degree
Bachelor Degree
Masters Degree
Doctorate Degree
22
Name of the Spouse* This field is required.
First Name
Middle Name
Last Name
23
Spouse Driver License Number* This field is required.
24
Spouse State of the License* This field is required.
Please Select
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
25
Spouse Gender* This field is required.
Male
Female
26
Spouse Date of Birth* This field is required.
Date
Month
Day
Year
27
Spouse Cellphone Number* This field is required.
28
Spouse Other Phone Number
29
Spouse E-mail* This field is required.
example@example.com
30
Spouse Highest Educational Level
Lower Than High School
High School
Vocational/Trade School Graduate
Some College
Associate Degree
Bachelor Degree
Masters Degree
Doctorate Degree
31
Resident Type
Please Select
Please Select
Rent
Own Home
Live w/Parents or other
Own Condo
Own Mobile Home
32
How Many Vehicles Are We Quoting* This field is required.
NONE
1
2
3
more than 3
33
What is the status of the vehicle* This field is required.
Financing (with Lien Holder)
Own (No payments owed)
Lease
34
Make of the Car* This field is required.
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
Pontiac
Porsche
Ram
Rolls-Royce
Smart
Subaru
Tesla
Toyota
Volkswagen
Volvo
35
Year & Model of the Car* This field is required.
Seperate Multiple Vehicles with a COMMA (,)
36
VIN#* This field is required.You can find this number on your REGISTRATION OR AUTO INSURANCE DEC PAGE
17 characters
37
How Long Have You Owned This Vehicle* This field is required.
Less Than 1 year
1-3 Years
5 years or more
38
Have any drivers had any accidents, violations or claims during the past 5 years?* This field is required.
Yes
No
39
Incident Type* This field is required.
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
40
Make of the 2nd Car* This field is required.
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
Pontiac
Porsche
Ram
Rolls-Royce
Smart
Subaru
Tesla
Toyota
Volkswagen
Volvo
41
What is the status of the 2nd vehicle* This field is required.
Financing (with Lien Holder)
Own (No payments owed)
Lease
42
Year & Model of the 2nd Car* This field is required.
Seperate Multiple Vehicles with a COMMA (,)
43
VIN#* This field is required.You can find this number on your REGISTRATION OR AUTO INSURANCE DEC PAGE
17 characters
44
How Long Have You Owned This Vehicle* This field is required.
Less Than 1 year
1-3 Years
5 years or more
45
Have any drivers had any accidents, violations or claims during the past 5 years?* This field is required.
Yes
No
46
Incident Type* This field is required.
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
47
Make of the 3rd Car* This field is required.
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
Pontiac
Porsche
Ram
Rolls-Royce
Smart
Subaru
Tesla
Toyota
Volkswagen
Volvo
48
What is the status of the 3rd vehicle* This field is required.
Financing (with Lien Holder)
Own (No payments owed)
Lease
49
Year & Model of the 3rd Car* This field is required.
Seperate Multiple Vehicles with a COMMA (,)
50
VIN#* This field is required.You can find this number on your REGISTRATION OR AUTO INSURANCE DEC PAGE
17 characters
51
How Long Have You Owned This Vehicle* This field is required.
Less Than 1 year
1-3 Years
5 years or more
52
Have any drivers had any accidents, violations or claims during the past 5 years?* This field is required.
Yes
No
53
Incident Type* This field is required.
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
54
Which Car (if the Mate Drives) is There Primary Vehicle
If there's only 1 Car, type "SAME"
55
List Other Vehicles Here (Make & Vin#)You can find THE VIN NUMBER on your REGISTRATION OR AUTO INSURANCE DEC PAGE
56
Company/Business Name* This field is required.
57
Type of Business* This field is required.
Sole Proprietorship
Limited Liability Corporation (LLC)
Corporation
S-Corporation
Partnership
Other
58
EIN#* This field is required.
59
Year Established* This field is required.
60
Company/Business Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
61
Number of Employees 1009 * This field is required.
62
Number of Employees W-2* This field is required.
63
Business Website
64
Years of experience in the industry
65
What do you do/Scope of Business* This field is required.
i.e. Education, Retail Sales, Law
66
Use Any Vehicle for Business
Yes
No
67
Type of Premises * This field is required.
Leased Premises
Home Based
Building Owned & Occupied
68
Estimated Annual Payroll
69
How much coverage is requested for Business Personal Property (appliances, tables, chairs, cash register, etc.)* This field is required.
70
Any equipment of high value or with a lienholder/loss payee that needs to be scheduled individually
Yes
No
71
Do you need liquor liability
Yes
No
72
Do you have current business insurance
Yes
No
73
Do you have a website and can clients purchase goods or services on your website using a credit card
Yes
No
74
State Insured/Prospecting to be Insured* This field is required.
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
75
Current Insurance Provider* This field is required.
Farmers
Progressive
State Farm
Nationwide
Geico
USAA
Travelers
Liberty Mutual
Erie
AllState
Other
Not Insured
76
Current Monthly Premium
77
Are You Currently Employed* This field is required.
Yes
No
Retired
Self Employed
78
Is Your Spouse Currently Employed* This field is required.
Yes
No
Retired
Self Employed
79
Please List Occupation* This field is required.
80
Please List Spouse Occupation* This field is required.
81
What Agent Are You Working With* This field is required.Please Indicate the Insurance Agent
Dr. Tyrone Smith
Brian Steedley
Christopher Tauscher
Dominic Smith
Elise Jones
Jenelle Blue Faulkner
Kattina Young
Kia/Chevy Dealership
Other
82
Which Kia/Chevy Representative are you working with?* This field is required.Please Indicate the Salesperson
Paulette McBroom
Evan Lawson
Darin Pryer
Sterling Wright
Kahrae Mooring
George Johnson
Christopher Kender
Kris Curry Davis
Adrean Pope
Sunil Shahid
Tonya Tomlinson
83
Name the Person/Business who Referred You | Insurance Agent | Realtor/Loan Officer
Should be Empty: