No
No
No
If you live in Allegheny County this information is not necessary we have access
to the information on the Internet, for all other Counties Please fill out this form
to the best of your knowledge.
2.
3.
Estimated value of your special personal property that should be
specifically insured:
Ricci & Associates
Four Clairton Blvd.
Pittsburgh, PA 15236

Phone- 412-892-2424
Phone- 412-653-0303
Fax- 412-653-9463
Homeowners Quote Form
Contact Name:*
Social Security
Number:
Spouse's Name:
Spouse's Social Security Number:
Email Address:
Home Phone
Number:
Work Phone
Number:
Fax Number:
How would you like us to respond?:*
Property Location
Address:*
City:*
State:*
Zip:*
County:*
Is your home located within the city
limits?:*
 Yes
Current Insurance
Information
Company Name:
Current Annual Premium:
Expiration Date:
Property Loss
Deductible:*
Personal Liability Limit:*
Yes
Backup of Sewers
Desired?:
Yes
Mine Subsidence Desired:
Dwelling Information
Dwelling - Estimated Replacement
Cost:*
Year Constructed:
How Many Floors?
If your house was built before 1980 have you
updated:
(Please Check all that apply)
Electrical Wiring
Heating
Plumbing
Roof
Other
Other Features:
(Please Check all that apply)
Dead Bolts
 Swimming Pool
Smoke Detectors
 Trampoline
Fire Extinguisher
Central Station Fire
Alarm
Central Station Burglar
Alarm
Type of Construction:
Claims
Date Of Claim
 Amount Paid
 Claim Type
Description
1.
Scheduled Personal
Property
Jewelry & Watches:
Furs:
Silver, Gold, Platinum Items:
Fire Arms:
Stamp and Coin Collections:
Fine Arts and Breakable
Items:
* Indicates required fields
Questions and Comments:
If you were referred to our agency please specify who referred you to us.
Four Clairton Blvd. P.O. Box 18069 Pittsburgh, PA 15236     Phone: 412.892.2424   Fax: 412.653.9463
EMAIL