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Hey! I'm Rita. I'm here to help you through this. Tell me a little about yourself...
*How do you want to be contacted?
Now I need to know about the drivers in your household
*Your date of birth?
*Are you married or single?
*Spouse date of birth?
Any other additional drivers like kids? (Need name and date of birth)
Tell me about your vehicles and current insurance
*List All Vehicles
(Year, make & model)
*What insurance company are you currently with?
Tell me about where you live?
*What is your address?
*City, State and Zip code?
*Do you own the home or rent?
*Approx value of home?
*Year built of home?
*Square footage of home?
*Year roof was installed or replaced?
*Do you have any of the following?
(Hold down CTRL key to select multiple)
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*Does pool have slide or diving board?
*What breed of dog?
And finally any additional information we need to know?
Is there any additional information you would like us to know?
(If no, please skip)
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*How did you hear about us?
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Family/friend referred me
My Mortgage Broker
Name of person who referred you?
Name of mortgage broker?
Please tell us how you found us
14785 W. National Ave., New Berlin, Wisconsin, 53151
Insurance for your family
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