Name: Affinity Insurance Group
Address: 800 W Williams St, Apex, NC, 27502, US
Telephone: (919) 296-3787

Agency Partner, Personal & Commercial Lines

Michael is a licensed Property and Casualty Insurance agent with expertise in both personal and commercial lines.

With over seven years of industry experience, he serves as a partner in the family-owned independent agency, where he plays an integral role in managing operations and supporting the agency’s growth.

Michael values the relationships he builds with clients and takes pride in helping them feel confident and secure through customized insurance solutions.

A longtime resident of Apex, he lives with his wife, Aya. In his free time, Michael enjoys traveling abroad with Aya, spending time with friends, and giving back to the community through volunteer work.

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First Name*
Last Name*
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Phone*
Date Of Birth (MM/DD/YYYY)*
Are You An Active Client?*
Preferred Contact Method
Type of Insurance*
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Address
Street Address*
Second Address Line (Suite, Apartment, or Building #)
City*
State*
Zip Code*
Is This Address Also The Mailing Address?*
Mailing Address - Street Address*
Mailing Address - City*
Mailing Address - State*
Mailing Address - Zip Code*
Homeowners Insurance
Do you currently have homeowners insurance?*
Do you have a current homeowners insurance declaration page?*
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Max. file size: 59 MB.
Others Listed on Deed:*
Number Of Extra Persons Listed On Deed*
First Additional Person Listed On Deed
First Name*
Last Name*
Date Of Birth (MM/DD/YYYY)*
Second Additional Person Listed On Deed
First Name*
Last Name*
Date Of Birth*
Month
Day
Year
Third Additional Person Listed On Deed
First Name*
Last Name*
Date Of Birth*
Month
Day
Year
Homeowners Insurance Information
Property Street Address to Quote*
Property City to Quote*
Property State to Quote*
Property Zip Code to Quote*
For How Long You Have Been At This Property?*
Prior Property Street Address*
Prior Property City*
Prior Property State*
Prior Property Zip Code*
Is this your primary residence?*
Do you currently live at this property?*
Year property was built*
Type Of Property*
Desired coverage effective date*
Month
Day
Year
Current insurer (if applicable)
Square footage*
Number of stories*
Number of bathrooms*
Roof Type
Other Roof Type
Roof Age*
Exterior wall material (brick, siding, stucco, etc.)
Heating System*
Heating System Year Updated
Cooling System*
Cooling System Year Updated
Any galvanized, cast iron, PEX or polybutylene Pipes?
Garage type
Attached Garage Type
Basement*
Safety Features*
- Security System
- Fire Sprinkler System
- Smoke Detector
Do you own any high-value items you’d like to insure separately (jewelry, art, collectibles)?
Any recent claims in the past 5 years?*
Please describe claim*
Do you run a business from your home?*
Do you have any pets?*
How Many Pets?
First Pet's Type and Breed*
Second Pet's Type and Breed*
Third Pet's Type and Breed*
Fourth Pet's Type and Breed*
Fifth Pet's Type and Breed*
Auto Insurance
Do You Currently Have Auto Insurance?*
Do you have a current auto insurance declaration page?*
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Number Of Vehicles*
Vehicle Information
Year*
Make*
Model*
Vehicle Identification Number (VIN)*
Ownership*
Primary Use*
Primary Driver*
Annual Mileage*
Any customized equipment?*
Value of customized equipment*
Towing*
Extended Transportation Vehicle 1*
Extended Transportation Amount Vehicle 1*
Vehicle Information 2
Year*
Make*
Model*
Vehicle Identification Number (VIN)*
Ownership (Owned / Financed / Leased)*
Primary Use (Commute / Pleasure / Business)*
Primary Driver*
Annual Mileage*
Any customized equipment on second vehicle?*
Value of customized equipment*
Towing*
Extended Transportation Vehicle 2*
Extended Transportation Amount Vehicle 2*
Vehicle Information 3
Year*
Make*
Model*
Vehicle Identification Number (VIN)*
Ownership (Owned / Financed / Leased)*
Primary Use (Commute / Pleasure / Business)*
Primary Driver*
Annual Mileage*
Any customized equipment on third vehicle?*
Value of customized equipment*
Towing*
Extended Transportation Vehicle 3*
Extended Transportation Amount Vehicle 3*
Vehicle Information 4
Year*
Make*
Model*
Vehicle Identification Number (VIN)*
Ownership (Owned / Financed / Leased)*
Primary Use (Commute / Pleasure / Business)*
Primary Driver*
Annual Mileage*
Any customized equipment on fourth vehicle?*
Value of customized equipment*
Towing*
Extended Transportation Vehicle 4*
Extended Transportation Amount Vehicle 4*
Vehicle Information 5
Year*
Make*
Model*
Vehicle Identification Number (VIN)*
Ownership (Owned / Financed / Leased)*
Primary Use (Commute / Pleasure / Business)*
Primary Driver*
Annual Mileage*
Any customized equipment on fifth vehicle?*
Value of customized equipment*
Towing*
Extended Transportation Vehicle 5*
Extended Transportation Amount Vehicle 5*
Driver Information
Driver's License Number*
State of issue*
Years licensed*
Marital Status (Single / Married / Divorced / Widowed)*
Currently insured?*
Current insurance company (if applicable)
Policy expiration date
Any accidents or violations in the past 5 years?*
Desired Coverage Effective Date*
Month
Day
Year
Liability Limits*
Other Liability Limit*
Uninsured/Underinsured Motorist Limits*
Other Uninsured/Underinsured Motorist Limits*
Medical Payments Coverage*
Comprehensive Coverage?*
Comprehensive Deductible Preference*
Collision Coverage?*
Collision Deductible Preference*
Any additional drivers?*
How Many Additional Drivers?*
Additional Driver 1
Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 1*
Other*
Additional Driver 2
Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 2*
Other*
Additional Driver 3
Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 3*
Other*
Additional Driver 4
Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 4*
Other*
Additional Driver 5
Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 5*
Other*
Life Insurance
Do you qualify for Erie Express Life? Ages of 19 to 40 qualifies (NO PHYSICAL REQUIRED).
- Yes
- No
Smoker or Non-Smoker?*
Height*
Weight*
Type of Life Insurance Policy*
Face Amount $250,000, $500,000 or whatever amount preferred*
Term Policy Years*
Business Insurance
Do You Currently Have Business Insurance?
Current Carrier
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Effective Date*
Month
Day
Year
Name of Owner*
Owner Mailing Street Address*
Owner Mailing Address City*
Owner Mailing Address State*
Owner Mailing Address Zip Code*
Owner Cell Phone*
Owner Email*
Additional Owner's Name (if applicable)
Additional Owner's Email (if applicable)
Name of Business*
Business DBA
Business Address 1*
Business Second Address Line*
Business Address City*
Business Address State*
Business Address Zip*
Business Phone
Website (if applicable)
Federal Tax ID or SSN*
Business Entity (LLC, Corp, S-Corp, Sole Prop)*
Type of Business (Brief Description)*
Years in Business*
Years Experience in the field*
Gross Sales (est.)*
Annual Payroll (est.)*
Business Personal Property Coverage ($)
Number of Full Time Employees*
Number of Part-Time Employees*
Percentage of Work Subcontracted
Building Coverage*
Building Value ($)
$0.00
Building Sq. Ft. (or rental space sq ft)*
Fire Alarm
Burglar Alarm
Sprinkler System (0-100%)
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Contact

Phone: (919) 296-3787

Fax: (919) 296-3788

Email: info@affinityinsurancenc.com

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Michael Petilli