Ortiz Agency Intake Form

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How many Autos to be insured

One VehicleMultiple Vehicles

Vehicle VIN

Additional VIN#s(one per line)

Current Coverage

Additional coverages

Rental ReimbersementTowing and roadside assitanceGAPGlass buyback deductible

Current Insurers

Home Ownership status

PurchasingOwnRenting

Roof Age

Expected Closing Date

Date

Occupation

Additional Insureds(Spouse, children, parents, etc)

By clicking “Submit,” I provide my electronic signature and give express written consent to Ortiz Insurance Agency and its representatives to contact me at the phone number provided above, including by text message and telephone call, for account notifications, customer care, and marketing purposes, using automated technology as permitted by law, even if my number is listed on a state, federal, or corporate Do Not Call registry.

Consent is not a condition of purchasing any goods or services.
Message frequency may vary. Message and data rates may apply.
I may revoke my consent at any time by replying STOP to any text message. For assistance, reply HELP or contact the agency directly.

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SMS Terms & Conditions.

I consent to:

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