Enter Your Name

First Name *

Last Name *

Phone *

When Were You Born?

Date of Birth *

When Was Your Roof Last Replaced?

Roof Replacement Year *

Where Do You Live?

Address

City *

State *

Postal code *

Contact Information

Email *

Disclaimer

Disclaimer: By submitting this form, I consent to receive communications from the Luke Bortz Farmers Agency, Rebecca Phillips Farmers Agency and its partners regarding insurance products and services. Even if my number is listed on any company-specific, state, or federal Do-Not-Call list, regarding insurance products and services, including but not limited to calls, SMS messages, AI-generated calls, and emails, at the phone number and email provided. Which I confirm is my phone number and not someone else's. Message frequency may vary, and standard messaging and data rates may apply. I understand that my consent is not a condition of purchasing any goods or services and that I may revoke my consent at any time by contacting the agent or replying STOP to unsubscribe or HELP for assistance. I confirm this is my number on this form and not someone else's. Additionally, I understand that the insurance companies may confirm my information through the use of a consumer report.