Evangelical Family Insurance Plan
Quick Quote Form
The Evangelical Family Insurance Plan has been designed to provide families with "Peace of Mind" Coverage Solutions for Home and Auto.
30%   Auto
25% Home
25% Business
27% Church

Special Group Rate Plan
Application
My Affiliation
Church Affiliation
CMA AGC Baptist Community Church Other    
Business
Employee
Retiree
Pastor
Donor
CCC Alumni
Volunteer
Occupation
  Name  
  Address  
Contact Home Phone
  Work Phone
  Email
  For Home Insurance
Replacement Value
  Age
  Alarmed No    Yes
  Claims No    Yes
Current Insurer Renewal Date
For Auto Insurance
 
Auto #1
Auto #2
  Make of Auto
  Model & Year
  Distance to Work
  After Market Car Alarm   Yes    No   Yes    No
Current Insurance Company
  Renewal Date on Your Pink Slip
  Number of Tickets
  Accidents Yes    No
Were You Charged? Yes    No
  If Yes, Provide Dates
  Age of Drivers #1   #2   #3
Drivers License Number
for Primary Driver
For Your Records, Before Submitting The Form
We will contact you with a Quick Quote
To Follow Up
Call Today for Peace of Mind Insurance
905-764-7868     1-800-917-SAVE     fax: 905-764-9618
JD Smith & Assoc. Insurance Brokers Inc.
JD Smith Insurance.com
email