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Name:
Email:
Phone:
Street
City
State
Zip / Postal Code
Date of Birth
Social Security Number (Optional)
Do you currently have insurance?
No
Yes
Current Premium (optional)
Current Insurance Provider (optional)
Months with Company
1
2
3
4
5
6
7
8
9
10
11
12 or more
Current Policy End Date
Year Built (optional)
Roof Type (optional)
Asphalt Shingle
Clay Tile
Tin / Metal
Other
Roof Replacement
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
Construction Type (optional)
Slab
Basement
Stilts
Date of Original Purchase
Number of Families living in Home (optional)
Number of bedrooms (optional)
Deductible Amount (optional)
500.00
1000.00
2500.00
5000.00
Square Footage (optional)
Liability Limits (optional)
100,000
300,000
500,000
1,000,000
Estimated Value (optional)
Dogs?
Yes
No
Pool?
Yes
No
Claims/Property Losses in Past 5 years?
Yes
No
How did you hear about us?
Referral
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If you have lived somewhere else in the last 2 years, please enter that address including Street, City and Zipcode
Residence Type
Primary
Seasonal
Secondary (Split 50/50)
Rental Property
Is this a new purchase?
Yes
No
Thank you for contacting us.
We will get back to you as soon as possible.
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Contact Details
PalmettoBluffIns@gmail.com
3273 Argent Blvd, Unit 103E
Ridgeland, SC 29926
Phone: 912-228-5509
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