Insurance Proposal

Please select the type of proposal you would like to have:

Auto/ Recreational Vehicle Insurance

At Smith & Thomas we understand that after an accident you want prompt service to make sure that you can quickly get back on the road or water. Being an independent agency our agents have access to several companies to help you develop a policy that will provide you with the right amount of coverage within your budget. A policy with proper coverage can protect against medical and legal expenses that may arise from an accident that causes injury or property damage.

Proposed Effective Date?
How Did You Hear About Us?
First Name
Last Name
Social Security
Street
City
Zip
Best phone number to reach you
Email Address
Drivers License Number
Gender
Marital Status
Date Of Birth

Accidents & Violations For Driver One
Date
Date
Date

Driver Two First Name
Driver Two Last Name
Date Of Birth
Gender
Relationship
Drivers License Number

Accidents & Violations For Driver Two
Date
Date
Date

All Others In Household Over Age 14
Name:	DOB	Status:
Name:	DOB	Status:
Name:	DOB	Status:

Vehicle Info

Vehicle One VIN

Year, Make & Model

Comprehensive and Collision Coverage:

Deductable :

Antilock Brakes

Anti-Theft Device

Vehicle Two VIN

Year, Make & Model

Comprehensive and Collision Coverage:

Deductable :

Antilock Brakes

Anti-Theft Device

Vehicle Three VIN

Year, Make & Model

Comprehensive and Collision Coverage:

Deductable :

Antilock Brakes

Anti-Theft Device

Additional Information
Current Car Insurance Company
Current Bodily Injury Limits
Expiration Date of privious policy
Resident Status
Checking Or Savings Account
Note


* Social Security Number is required by most companies in order to review consumer reports such as ownership, prior coverage proof, claims history and credit rating. The underwriters we use may use credit history to provide you with the most appropriate rate.
If you choose not to have your consumer reports reviewed please check this box:

Property Insurance

Often a persons home is their largest investment. There are several options when choosing a policy. Home and property insurance can cover the policyholder’s physical residence along with its contents against damage or vandalism. Liability protects the policyholder in the case of an accident occurring to a person while on the property. Depending on the area in which the home is located a separate wind or flood policy may be needed. It is important to speak with an agent so that they can help you evaluate the coverage that you need to protect yourself and your home.

Proposed Effective Date?

How Did You Hear About Us?

First Name

Last Name

Property Street

City

Zip

County

Type Of Building

Occupancy Info

Best Phone number to reach you

Email Address

Year Built

Construction

Have you had an inspection performed?

Have you had a wind mitigation performed?

Roof Info

Age

Material

Roof Type

Updated

Updated Date

Electrical Info

Updated

Updated Date

Plumbing Info

Updated

Updated Date

Heating and Cooling Info

Updated

Updated Date

Heating and Cooling Source

Monitored Burglar or Fire Alarm

Fire Place

Garage/Carport

Number Of Stories

Sq FT

Storm Shutters

Guard/Gated

Within 1000 ft of hydrant?

Within 5 miles of Fire Station?

Pets? Type? Bite history?

Claims In Five Years?

Bankruptcy In Last 7 Years?

Prior Insurance? Expiration Date of Prior Policy

Any Additions To Home? (Porches, Decks, etc)

Pool

Screen/Fence

Diving board or slide

Notes


* Social Security Number is required by most companies in order to review consumer reports such as ownership, prior coverage proof, claims history and credit rating. The underwriters we use may use credit history to provide you with the most appropriate rate.
If you choose not to have your consumer reports reviewed please check this box:

Manufactured Home Insurance

Proposed Effective Date

Prior Insurance Company

Prior Insurance Expiration Date

Dwelling Coverage Amount (Policy Coverage A)

How Did You Hear About Us?

First Name

Last Name

Date of Birth

Property Street

City

Zip

County

Home Location

Lot Size

Name Of Park Or Subdivision

If you have a mortgage, Name Of Mortgage Company

Is Insurance Escrowed?

Occupancy Info

Best Phone Number to reach you

Email Address

Year Built

Manufacturer Name

Roof Info

Age

Material

Roof Type

Updated

Updated Date

Electrical Info

Updated

Updated Date

Plumbing Info

Updated

Updated Date

Heating and Cooling Info

Updated

Updated Date

Heating and Cooling Source

Monitored Burglar or Fire Alarm

Fire Place

Garage/Carport

Length x Width

Skirting

Porches Or Decks

Window/Door Awnings

Utility Shed

Room Additions

Guard/Gated

Within 1000 ft of hydrant?

Within 5 miles of Fire Station?

Pets? Type? Bite history?

Claims In Three Years?

Bankruptcy In Seven Years?

Pool

Screen/Fence

Diving board or slide

Notes


* Social Security Number is required by most companies in order to review consumer reports such as ownership, prior coverage proof, claims history and credit rating. The underwriters we use may use credit history to provide you with the most appropriate rate.
If you choose not to have your consumer reports reviewed please check this box:

Life Insurance

As the the old saying goes “Failing to make a plan is planning to fail.” Having the right life insurance policy is essential to fulfilling promises and providing for loved ones. No matter what stage in life Smith & Thomas Insurance offers a variety of life insurance policies to fit you and your family's needs.

First Name
Last Name
Street
City
Zip
Phone Number
Email Address
Occupation
Type of Coverage
Requested Amount of Coverage
Date of Birth
Height
Weight
Tobacco User
Note


* Social Security Number is required by most companies in order to review consumer reports such as ownership, prior coverage proof, claims history and credit rating. The underwriters we use may use credit history to provide you with the most appropriate rate.
If you choose not to have your consumer reports reviewed please check this box:

First Name
Last Name
Title
Phone Number
Email Address
Type of Business
Note


* Social Security Number is required by most companies in order to review consumer reports such as ownership, prior coverage proof, claims history and credit rating. The underwriters we use may use credit history to provide you with the most appropriate rate.
If you choose not to have your consumer reports reviewed please check this box:

Please select the type of proposal you would like to have:

Auto/ Recreational Vehicle Insurance

Accidents & Violations For Driver One

Accidents & Violations For Driver Two

All Others In Household Over Age 14

Vehicle Info

Additional Information

Property Insurance

Manufactured Home Insurance

Life Insurance

Business Insurance