RICCI & ASSOCIATES
INSURANCE SERVICES
We spend the time to SAVE YOU MONEY!
Contact Name*
Email Address
Home Phone
Work Phone
Fax No.
Preferred Contact
Method
Property Location
Address
City
State
Zip
County
No. of yrs. with
Company
Current Insurance
Company
Current Annual
Premium
Policy Expiration
Date
Personal
Liability
Property Loss
Deductibe
Yes
 No
Water backup of Sewers/Drains Included?
Dwelling Information
*If you are a resident of Allegheny County, most information is available to us on the internet;
for all other counties, please fill out the additional information to the best of your knowledge
Type of Home
Dwelling
Replacement Cost
(Estimate)
Year Constructed
Recent Updates to home (within past 10 yrs/20 yrs. if built before 1980):
Electrical/Wiring
 Heating
Plumbing
 Roof
 Other
Type of Construction
Yes
No
Claim/s Within
Past 3 Years?
Explanation
Questions/Comments
How did you hear about us?/Referral
Home Quote
Please fill out the information below; We will contact you within the next business day with a quote.