Home and Auto Quote Form

How did you hear about us?

Name

First NameLast Name

Date of Birth

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 you at this number?

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary Insured

First NameLast Name

Secondary Insured's Date of Birth

Date

Desired Coverage Start Date

Date

Is this home a new purchase?

If New Purchase what is the closing date?

What is your home usage type?

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?

Roof Material

Plumbing Type

Wall Type

What type of flooring do you have in your house? If multiple, please give an estimate on % of each kind.

Do you have the following:

Rows	Yes	No
Monitored Central Burglar Alarm
Monitored Central Fire Alarm
A Fire Hydrant outside within 1000 Feet of your home
Do you live in a gated community?
Do you have a fire place?
Have you filed for bankruptcy, Foreclosure, Repossession or Short Sale in the past 5 years?
Have you had your home insurance canceled, non-renewed or denied coverage?
Are there any dogs with bite history?

Please upload current declarations page if available

Full Drivers License Number

Drivers License Issue Date

Drivers License Expiration Date

How long have you lived at this residence?

Do you require a sr-22?

How many miles do you estimate you drive a year?

Secondary Insured Full Drivers License Number

Secondary Drivers License Issue Date

Date

Secondary Drivers License Expiration Date

Date

What were your prior liability limits on your last auto policy?

Do you want Comprehensive Coverage on your vehicles

Do you want Collision Coverage on your vehicles?

Do you want Towing?

Do you want rental coverage?

Do you want glass coverage?

How old were you when you got your first drivers license?

How Many Vehicles do you own?

How many drivers are in the household?

What is the year, make & model of EACH Vehicle you would like insured?

If you have more then just the 2 drivers above please list EACH driver's Full name, Date of Birth, Driver's License State, Drivers License Number, Expiration Date & Issued Date.

Please note quote will not be completed without all of this information. Please make sure if you have teenagers that this is included for them as well.

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.on