Details needed to start your policy

Complete only those sections requested in the email that provided this link and scroll to the end and submit.

Name*
First Last
Email*
An email link brought you here. Refer back to that email and fill in only those sections 1-7 that are requested.
1. Social Security Numbers
Your Social Spouse/Significant

2. Driver's License Numbers

Driver's Name and DL#	Driver's Name and DL#	Driver's Name and DL#

3. PAYMENT INSTRUCTIONS
Checking Account Information
Account Number Routing Number
If you pay the home insurance, should we use the same account shown above?
- Yes
- No
We will use the same day of the month as the auto policy unless indicated here:
We will use the same day of the month as the auto policy unless indicated here:
For Home: How would you like to pay?
- monthly using the electronic payment transfer [EFT]
- in full for the year
4. TO ALL: Payment Authorization
We prefer to process the payment early to have time to get apps signed, etc. and to prevent your current carrier from drawing another payment.
Check which applies
- Yes, I have the funds – process as soon as possible.
- No, don’t process the payment until *____
*If you selected no, fill in date here
*If you selected no, fill in date here
5. Start date?
Refer to the email to know the policy need a start date.
Start date? [When should we start the policies?]
Auto Home/Condo/Renters Rental Property Seasonal/Secondary Home
6. Mortgage Lender

Lender Name	Loan Number	Is insurance paid from escrow?	Contact Person [for new loans]

7. Lender/lease on autos
Auto 1
Year/Make of Auto Lender Name or Lease Company
Indicate a Lease or Loan for Auto 1
- Lease
- Loan
Auto 2
Year/Make of Auto Lender Name or Lease Company
Indicate a Lease or Loan for Auto 2
- Lease
- Loan
Auto 3
Year/Make of Auto Lender Name or Lease Company
Indicate a Lease or Loan for Auto 3
- Lease
- Loan
Refer to your original email to see if we requested any of these documents. If we did, simply send them through an email. Report cards, jewelry or other appraisal, proof of prior insurance, wood stove questionnaire, etc.
8. Personal Contact Information
List Name, Cell Phone and Email for drivers in the household
Place your comments here
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Pat and team are awesome. They are prompt, courteous and always go above and beyond to make sure I understand my policy and that...

7 months ago

BR Rupert

Greg, Pat, and the entire team are top notch and true professionals. They take the time to understand your insurance needs and in my case...

a year ago

Robert Szucs

The staff at Select Insuranse are all top shelf. They were very friendly and eager to help us with our insurance questions, and provided a...

3 years ago

Timothy Wiley

Select Insurance Services always goes above and beyond! Their team reached out to Grange during our last auto renewal (without us asking) and got us an...

4 years ago

Michael Iacianci

Auto	Home/Condo/Renters	Rental Property	Seasonal/Secondary Home

Your Social	Spouse/Significant

Account Number	Routing Number

Year/Make of Auto	Lender Name or Lease Company

Year/Make of Auto	Lender Name or Lease Company

Details needed to start your policy

Details needed to start your policy

An email link brought you here. Refer back to that email and fill in only those sections 1-7 that are requested.

3. PAYMENT INSTRUCTIONS

4. TO ALL: Payment Authorization

5. Start date?

6. Mortgage Lender

7. Lender/lease on autos

8. Personal Contact Information

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