Florida Home Quote Form

Home Quote
How did you hear about us?*
If refered by a client, please let us know in the comments below.
Are you a Current Client?*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Marital Status
Occupation (If Retired what occupation did you retire from?)
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Do we have permission to text your quote and other details to this number?*

YesNo
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address if different then above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insured or Spouse

First NameLast Name
Secondary/Spouse Insured's Date of Birth

MonthDayYear
Date
Desired Coverage Start Date*

MonthDayYear
Date
Date of Purchase
If new purchase what is your closing date?
Home Type*
How is the home occupied?*
What year was your home built?*
What is the square footage of your home? *
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 *
Plumbing Type
Wall Type
Monitored Central Burglar Alarm

YesNo
Monitored Central Fire Alarm

YesNo
A Fire Hydrant outside within 1000 Feet of your home

YesNo
Do you live in a gated community?

YesNo
Do you have a fire place?

YesNo
Have you filed for bankruptcy, Foreclosure, Repossession or Short Sale in the past 5 years?

YesNo
Have you had your home insurance canceled, non-renewed or denied coverage?

YesNo
Is the property located on more then 5 acres?

YesNo
Is the home built OVER water?

YesNo
Has the property had any sink hole activity?

YesNo
Are there any dogs with bite history?

YesNo
Do you have a pool?

YesNo
Do you have a screened enclosure?

YesNo
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

Cancelof
Please upload Wind Mitigation Inspection if available

Cancelof
Please upload current declarations page if available

Cancelof
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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