Permission to Contact and Optional Coverage Form
Our agency standard is to receive permission from you before using your mobile number for service and marketing purposes, sending you a text message, and before using an automated dialer to leave you a message (We often use an automated dialer and a text message to notify you of an upcoming policy renewal and to leave you birthday and holiday greetings.) Providing your mobile number as a contact number constitutes express consent that our agency can use that number to contact you by the methods you select below
First Name *
Last Name *
What is the PRIMARY contact number to reach you to discuss insurance related items?
Is the primary number you provided above a mobile number
Clear selection
If you provided a mobile number, may we text message you if it is important that we contact you and/or to send you a birthday greeting?
Clear selection
If you did not provide a mobile number but would like to, please do so in the box below:
Additional contact numbers or emails you want to add to your file?
Please use a comma to separate multiple entries
Optional Coverage Section
Please read the description of the optional coverage and accept or decline adding the coverage to your policy or insurance profile. These are optional coverage and are not part of your base policy or personal insurance profile. Any accept answer will trigger a call from the agency concerning the coverage. Only mark accept if you want to add the coverage or you want to discuss the coverage.
Towing and Lockout Reimbursement
Pays the cost of labor done at the initial place of accident or breakdown as well as towing, up to policy limits. Also covers for a locksmith. (Est cost $3/month per vehicle)
Clear selection
Rental Reimbursement
Reimbursement for the cost of a replacement vehicle in the event of a covered loss (Est cost $8/month per vehicle) based on the daily amount selected
Clear selection
Identity Restoration Coverage
Provides reimbursement up to $25,000 for covered expenses such as: attorney's fees, lost wages, loan application fees, & other expenses. Also helps pay up to $2,000 in costs for hiring a firm for assistance. (Est cost $30 Annually)
Clear selection
Scheduled Personal Property
(SPP) is a convenient way to extend coverage for your valuable items such as: jewelry, furs, watches, silverware, fine artwork, golf equipment, and collectibles. These items have limitations. (Average $9 per thousand scheduled) Highly recommended for individual items of jewelry valued over $1,000.
Clear selection
Flood Coverage
Property insurance does NOT cover flood damage. You must obtain a policy through the Federal Emergency Management Agency (FEMA) if additional coverage is needed. We can sell and administer this policy for you!
Clear selection
Personal Umbrella Protection - (PUP)
When purchased, a Personal Umbrella Policy provides additional financial protection beyond the base limits found on your auto and propert policy. You must meet all of the qualifying guidelines to purchase this optional policy
Clear selection
Life Insurance and other Financial Services products *
We strongly recommend that you meet with our in house life insurance expert. They can assist you in all areas of financial services such as life insurance, disability, long term care, as well as retirement planning.
Please click on any additional policy type you would like our agency to quote for you.
Send us a referral and if they qualify to receive a quote you will earn a $25.00 restaurant.com gift certificate. (One certificate per policy quoted) While we appreciate each referral you send to us, we can only reward you for the referrals that meet our qualifying guidelines. Each policy type has its own unique qualifying guidelines. Send us the referral and we will let you know immediately if you are eligible for the reward. Put the referrals name and the best contact phone number and/or email for them in the box below.
We at ?????? insurance agency work hard to provide the best overall experience available in the insurance industry. Please take a moment to write a short review or comment about our agency that we can post on our website and share with others that are trying to find out more information about our agency. Long or short, your comments are very valuable to us. Thank you in advance for your time and your kind words. Put your comment in the box below.
Which of our staff serviced you today? *
By clicking the submit button I acknowledge and understand that it constitutes express written consent that the ???????? insurance agency can contact me at the phone numbers I have provided on this form, for the purposes stated above, by a combination of live calls, automated calls, or text message as selected by me.
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