Auto + Home Smart Intake

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Application

Complete each section below. Auto, Home, Business, Life, and package forms keep their own required questions.

I agree to receive recurring customer-care SMS text messages from A Jackie Dees Insurance Agency at the mobile number I provided regarding my insurance inquiry, quote, policy, appointment, requested documents, or service request. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. Consent is not a condition of purchasing insurance. Privacy Policy · Terms & Conditions · Text Message ConsentSMS consent is optional and is not required to submit this insurance request. Leave the box unchecked and choose Email or Phone if you do not want text messages.

Section 1

Shared applicant & primary driver

First nameMiddle name / InitialLast nameCo-applicant full legal nameEmail addressPhone numberCurrent addressMailing address, if differentCityStateZIP codeMove-in dateHow long at this address?Social Security NumberProtected information. Stored encrypted and masked by default in the agency workspace.Date of birthProtected information. Stored encrypted and masked by default in the agency workspace.Is the applicant the primary driver?Applicant driver-license stateApplicant driver-license numberProtected information. Stored encrypted and masked by default in the agency workspace.Applicant driver-license expirationProtected information. Stored encrypted and masked by default in the agency workspace.Applicant license statusMarital statusResidence typeEmployment statusOccupation and dutiesRequested effective datePreferred contact method

Section 2

Address history

Previous address

Add prior residences needed for underwriting. These remain connected to the applicant's address history.

No previous address added. Add one only when applicable.

Section 3

Auto · Additional drivers

Additional driver

The applicant is already captured as the primary driver by default. Add only other household members or operators that must be listed.

No additional driver added. Add one only when applicable.

Section 4

Auto · Vehicles

Vehicle

Vehicle 1

VINYearMakeModelTrimBody styleGaraging addressGaraging ZIPOwnership or lease statusDate acquired or length of ownershipLienholder or lessorPrimary driverSecondary driversEstimated annual mileageVehicle use Pleasure Commute Business use Farm use Rideshare or TNC Food or package delivery Taxi, livery, or for-hire OtherCurrent odometer, when required by the agency’s quoting contractProspect-verifiable safety or anti-theft equipment

Section 6

Current insurance

Currently insured?Any lapse in coverage?Cancellation or nonrenewal details

Section 7

Coverage & interests

Liability coverage packageUninsured/underinsured motorist preferenceComprehensive deductible preferenceCollision deductible preferenceOptional auto protections Rental reimbursement Towing Roadside assistance OtherDesired dwelling coverage, when knownDesired personal-property coverage, when knownReplacement-cost preferenceDeductible preferenceScheduled or high-value property to discuss?Lienholders or additional interestsMortgagee and additional interestsInterested in reviewing bundled coverage?

Section 8

Claims & incidents

Accident, violation, or claim

No accident, violation, or claim added. Add one only when applicable.

Property or liability claim

No property or liability claim added. Add one only when applicable.

Section 9

Documents

Optional supporting PDFs

Up to 10 PDF files, 25 MB each. Files are validated and security-scanned before storage.

Auto + Home Smart Intake