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Home Quote
How did you hear about us?
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Google
Facebook
Other Social Media
A Customer Referred Me
Neighborhood App
Magazine vs Newspaper or Bit
Drive by/Saw Your Sign
Met An Agent At An Event
My Mortgage Lender Referred Me
My Realtor Referred Me
Chamber or Rotary Event
If refered by a client, please let us know in the comments below.
Are you a Current Client?
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Yes
No
Name
*
First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Marital Status
Please Select
Married
Single
Divorced
Occupation (If Retired what occupation did you retire from?)
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Do we have permission to text your quote and other details to this number?
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Yes
No
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address if different then above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insured
First Name
Last Name
Secondary Insured's Date of Birth
-
Month
-
Day
Year
Date
Desired Coverage Start Date
*
-
Month
-
Day
Year
Date
Date of Purchase
If new purchase what is your closing date?
Home Type
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Single Family Home
Condo/ Townhome with HOA that has insurance for the exterior
Condo/ Townhome NO HOA Insurance
Apartment
How is the home occupied?
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Owner Occupied
Rented to Others
Owner Occupied part time and rented to others part time
Vacant
What year was your home built?
*
What is the square footage of your home?
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How many stories is your home?
*
What year is your roof?
What year is your hot water heater?
What year was your HVAC last updated?
Roof Material
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Please Select
Shingles
Metal
Tile
Other
Plumbing Type
Please Select
Copper
Galvanized
PEX
Polybutylene
PVC
Wall Type
Please Select
Masonry
Frame
Mixed Masonry-Frame
Monitored Central Burglar Alarm
Yes
No
Monitored Central Fire Alarm
Yes
No
A Fire Hydrant outside within 1000 Feet of your home
Yes
No
Do you live in a gated community?
Yes
No
Do you have a fire place?
Yes
No
Have you filed for bankruptcy, Foreclosure, Repossession or Short Sale in the past 5 years?
Yes
No
Have you had your home insurance canceled, non-renewed or denied coverage?
Yes
No
Is the property located on more then 5 acres?
Yes
No
Is the home built OVER water?
Yes
No
Has the property had any sink hole activity?
Yes
No
Are there any dogs with bite history?
Yes
No
Do you have a pool?
Yes
No
Do you have a screened enclosure?
Yes
No
What type of flooring do you have in your house? If multiple, please give an estimate on % of each kind.
Who is your current insurance carrier?
Please upload 4 Point Inspection if available
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Please upload Wind Mitigation Inspection if available
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Please upload current declarations page if available
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Cancel
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Any additional notes you would like us to know?
By submitting this form, I authorize the Steffanie Rigetta Agency, or one or more of agents or brokers which we represent to obtain a credit-based insurance score for myself and any co-applicant(s), which may be used for underwriting or rating purposes, and will not affect credit score. I authorize Steffanie Rigetta Agency to contact me at the email and/or phone number I provided for marketing purposes, including using an automatic telephone dialing system and/or prerecorded voice even if my number is on a Do Not Call list. I acknowledge that I can revoke consent at any time by contacting Steffanie Rigetta Agency at (407) 775-3001 or service@rigettainsurance.comConsent to receiving automated calls or SMS texts is not a condition of purchase.
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