The Smith Firm and Agency

Property and Casualty Form

Products of Interests (Click all that apply) *

Auto

Home/Renters

Loan Officer, Realtors, Processor

First and Middle Name *

Last Name *

Current Address

Address *

Street Address

City

State

Country

Postal Code

Resident Type

Please Indicate Purchase Type *

Refinance

New Purchase

Renters

Closing Date *

Mortgagee *

Property Address (Property to be Purchased) *

Other Mortgagee (Please include address. P.O. Accepted)

Loan Amount (if known)

Loan Number (if known)

State Insured/Prospecting to be Insured *

Current Insurance Provider (home insurance) *

If Other List Insurance provider here (home insurance)

Current Monthly Premium (home insurance) *

Marital Status *

Date of birth *

Driver License Number *

State of the License *

Gender *

Male

Female

Highest Education Level *

Are You Currently Employed *

Yes

Retired

Self Employed

Please List Occupation *

Phone *

I Consent to Receive SMS Notifications, Alerts from Smith Firm & Agency. Message frequency varies. Message & data rates may apply. Text HELP to 443-264-4398 for assistance. You can reply STOP to unsubscribe at any time.

I also agree to terms & conditions provided by the company. By checking the box and providing your consent at the end of the appointment form, you are agreeing to receive notifications and promotional SMS from the Smith Firm & Agency. You may opt-out in the future by replying STOP to any message.

Other Phone Number

Email *

Name of Spouse

Spouse Date of Birth

Spouse Driver License Number

Spouse State of the License

Spouse Gender

Male

Female

Spouse Cellphone Number

Spouse Other Phone Number

Spouse E-mail

Spouse Highest Educational Level

Is Your Spouse Currently Employed

Yes

Retired

Self Employed

Please List Spouse Occupation

How Many Vehicles are we Quoting *

What is the Status of the Vehicle(s) *

Separate multiple vehicles with a COMMA(,)

Make of the Car(s) *

Separate multiple vehicles with a COMMA(,)

Year & Model of the Car(s) *

separate multiple vehicles with a COMMA(,)

VIN #(s) (you can find this number on your registration or auto insurance dec page) *

separate multiple VIN #'s with a COMMA(,)

How long have you Owned This Vehicle(s) *

Separate multiple cars with a COMMA(,)

Have any drivers had any accidents, violations or claims during the past 5 years ? *

Yes

Incident Type *

Which Car (if the Mate Drives) is the Primary Vehicle *

If there's only 1 Car, type "SAME"

State Insured/Prospecting to be Insured for car insurance *

Current Insurance Provider (car insurance) *

If Other, Please List Insurance Provider here (car insurance)

Current Monthly Premium (car insurance) *