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package quote test

Package Quote

Agent
Internal Use Only
How would you like to submit your information?*
Name*
First Last
Phone*
Email*
What type of policies are you uploading documents for?*
Multi-Policy Pricing May Apply
- Auto
- Boat
- Home
- Life
- Motorcycle/Scooter
- RV/Motorhome
- Umbrella
File*
Upload Current Policy Documentation
Drop files here or

Max. file size: 512 MB.
Check each policy type you'd like quoted.*
Multi-Policy Pricing May Apply
- Auto
- Boat
- Home
- Life
- Motorcycle/Scooter
- RV/Motorhome
- Umbrella

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Named Insured Information
Name*
First Last
Date of Birth*
Month
Day
Year
Married?*
- Yes
- No
Name (Spouse)*
First Last
Date of Birth*
Month
Day
Year
Phone*
Email*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Is your physical address the same as your mailing address?*
- Yes
- No
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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Drivers
Named Insured*
First Last
Date of Birth*
Month
Day
Year
Drivers License State & Number*
State of Issuance License Number
Any other drivers in the household?
- Yes
- No
Name (Spouse)
First Last
Date of Birth*
Month
Day
Year
Drivers License State & Number*
State of Issuance License Number
Any other drivers in the household?
- Yes
- No
Name
First Last
Date of Birth*
Month
Day
Year
Drivers License State & Number*
State of Issuance License Number
Relationship to Named Insured
Any other drivers in the household?
- Yes
- No
Name
First Last
Date of Birth*
Month
Day
Year
Drivers License State & Number*
State of Issuance License Number
Relationship to Named Insured
Any other drivers in the household?
- Yes
- No
Name
First Last
Date of Birth*
Month
Day
Year
Drivers License State & Number*
State of Issuance License Number
Relationship to Named Insured

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Vehicles
How many vehicles would you like to insure?*
Vehicle 1*
Year Make Model VIN (Use "None" if unknown)
Vehicle 2*
Year Make Model VIN (Use "None" if unknown)
Vehicle 3*
Year Make Model VIN (Use "None" if unknown)
Vehicle 4*
Year Make Model VIN (Use "None" if unknown)
Vehicle 5*
Year Make Model VIN (Use "None" if unknown)

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Auto Coverages
Bodily Injury Liability Coverage*
Per Person/Per Accident
Property Damage Liability Coverage*
Per Accident
Medical Payments Coverage*
Choose your Medical Payments Coverage limit.
Vehicle 1
Year Make Model
Select Coverage for Vehicle 1
- Liability Only
- Full Coverage
Comprehensive Deductible*
Collision Deductible*
Towing/Roadside Assistance*
Per Use
Extended Transportation/Rental Car*
Per Day/Per Policy Period
Vehicle 2
Year Make Model
Select Coverage for Vehicle 2
- Liability Only
- Full Coverage
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible
Towing/Roadside Assistance*
Per Use
Extended Transportation/Rental Car*
Per Day/Per Policy Period
Vehicle 3
Year Make Model
Select Coverage for Vehicle 3
- Liability Only
- Full Coverage
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible
Towing/Roadside Assistance*
Per Use
Extended Transportation/Rental Car*
Per Day/Per Policy Period
Vehicle 4
Year Make Model
Select Coverage for Vehicle 4
- Liability Only
- Full Coverage
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible
Towing/Roadside Assistance*
Per Use
Extended Transportation/Rental Car*
Per Day/Per Policy Period
Vehicle 5
Year Make Model
Select Coverage for Vehicle 5
- Liability Only
- Full Coverage
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible
Towing/Roadside Assistance*
Per Use
Extended Transportation/Rental Car*
Per Day/Per Policy Period

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Motorcycle/Scooter Info
How many Motorcycles/Scooters would you like to insure?*
Motorcycle 1*
Year Make Model VIN (Use "None" if unknown)
CC's*
Curent Value
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible
Motorcycle 2*
Year Make Model VIN (Use "None" if unknown)
CC's
Current Value
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible
Motorcycle 3*
Year Make Model VIN (Use "None" if unknown)
CC's
Current Value
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible
Motorcycle Policy Coverage
Bodily Injury Liability Coverage*
Per Person/Per Accident
Property Damage Liability Coverage*
Per Accident
Medical Payments Coverage*
Choose your Medical Payments Coverage limit.

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RV/Motorhome*
Year Make Model VIN (Use "None" if unknown)
Current Value*
Unit Type*
Length*
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible
Bodily Injury Liability Coverage*
Per Person/Per Accident
Property Damage Liability Coverage*
Per Accident
Medical Payments Coverage*
Choose your Medical Payments Coverage limit.
Approximately how many weeks per year will the unit be used?*

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Home Information
Policy Type
- HO3 (Standard Single Family Home)
- HO4 (Renters Insurance, Personal Property Only)
- HO6 (Condo or Townhome)
- HE7 Plus 21 (High Value or Custom Home)
Internal Use Only
Do you own or rent?*
Type of Dwelling*
Heated Square Footage of Home*
What year was the home built?*
When was the roof last replaced?*
When was the heating system last serviced/replaced?*
When was the plumbing last replaced?*
When was the electrical system last replaced?*
How many homeowner claims have you had in the last 5 years?*
Applies to any homeowners policy within that time period.
Please provide claim details (type of loss, amount paid by carrier, etc.)

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Home Coverage
Dwelling Coverage*
The amount of coverage for the home itself.
Personal Property Coverage*
The amount of coverage for all contents within the home.
Liability*
Deductible*
Would you like to add any additional coverage?
- Jewelry Coverage
- Personal Property Replacement Coverage
- Water Backup Coverage
- Other
Total Value of Jewelry*
Include description and value of property if "Other" was selected*

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1. Watercraft Policy Coverage
Liability Coverage*
Choose your liability coverage limit.
Medical Payments Coverage*
Choose your Medical Payments Coverage limit.
Watercraft 1
Year Make Model
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible
Watercraft 2
Year Make Model
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible
Watercraft 3
Year Make Model
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible
Watercraft 4
Year Make Model
Comprehensive Deductible*
Choose your Comprehensive Deductible
Collision Deductible*
Choose your Collision Deductible

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Umbrella Coverage
Additional underlying limits are required to be eligible for an umbrella. Please make sure you've meet the following requirements. Auto Bodily Injury Liability- $250,000/$500,000, $300,000/$300,000 or Higher. Home Liability- $300,000 or Higher. RV, Motorcycle, Watercraft, or other "Toy" Liability- $300,000 CSL or Higher, or Equal to the Auto Liability Limits.
Liability Coverage Limit*
Deductible/Self Insured Retention*
Which items below do you own?*
- Auto
- Boat/Jet Ski
- Camper/Motorhome
- Home (Primary or Seasonal Residences Only)
- Motorcycle/Scooter/Moped/ATV/UTV
- Rental Properties
How many vehicles do you own?*
How many boats/jet skis do you own?*
How many camper/motorhomes do you own?*
How many residences do you own?*
Do not include properties you rent to others.
How many motorcycles/scooters/mopeds/ATV's/UTV's do you own?*
How many rental properties do you own?*

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Life/Retirement/Financial Planning
To start, please answer the questions below. They help the agent determine how much coverage would be necessary to protect you and your family.
Do you own your home?*
Have you recently changed jobs/careers?*
What is your liquid net worth?*
(cash, securities, etc.)
What is your annual household income?*
Do you believe you have enough life insurance ?*
Are you self-employed?*
Are you retired?*
When do you expect to retire?*
Do you need guaranteed retirement income?*
Life Insurance Info
Name of Insured*
First Last
Date of Birth*
MM slash DD slash YYYY
Has this person used any tobacco products in the last 12 months?*
Type of Policy*
Length of Term*
Face Amount*
Amount of Desired Coverage
Do you need another life insurance quote?
#2 Life Insurance Info
Name of Insured*
First Last
Date of Birth*
MM slash DD slash YYYY
Has this person used any tobacco products in the last 12 months?*
Type of Policy*
Length of Term*
Face Amount*
Amount of Desired Coverage
Do you need another life insurance quote?
#3 Life Insurance Info
Name of Insured*
First Last
Date of Birth*
MM slash DD slash YYYY
Has this person used any tobacco products in the last 12 months?*
Type of Policy*
Length of Term*
Face Amount*
Amount of Desired Coverage

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Is there any other information you'd like to provide?
- Yes
- No
Please include here...
....Or upload documents here.
Upload policy declarations or other documentation.
Drop files here or

Max. file size: 512 MB.

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Smart Insurance Services INC.

PO Box 3215
Mooresville, NC 28117
contact@smartinsuranceinc.com

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