Mancini Insurance
Agency
11269 Perry Hwy. #300
Wexford, PA 15090
Phone: 724-933-8637
Fax: 724-933-8600
Underwriting Information:
Describe IN DETAIL, Your Business Operations:
Ownership & Payroll Data:
List Employee's Annual Payroll Here (if none, enter $0):
$
Insert # of Employees here:
Location & Sales Information:
Insert Annual Gross Revenues from this operation here:
$
Square Footage of office or business location:
Type of Building (wood frame, concrete, etc.):
Number of Stories:
Are there other business/residences in this building (describe)?:
Describe safety features (alarm, sprinklers, fire protection, etc):
Coverage Desired: (Check One Please)
The Coverage I Am Looking For:
Liability Only
Liability & Business Contents
Liability, Building & Contents Coverage
A Package Policy Including the Above, Plus Miscellaneous Coverages
NOTE: Don't worry if you are not exactly sure about
coverage type... we will suggest the best coverage for you - just try to tell us what you are looking for! (If we need more info. we will let you know.)
Business Contents Coverage: (The amount of your personal business property)
$
Building Coverage: (The amount of building coverage if you own your bldg.)
$
Miscellaneous Coverage: (List any special coverage peculiar to your business, such as Garagekeepers Legal, Loss of Earnings, Valuable Papers, etc.)
$
Send my quotation via:
E-Mail Fax Regular Mail
Please Call by Phone!
Thank you for filling out this form
COMPLETELY!
We value your input as PRIVATE information. Every step has been
taken to insure your privacy, security, and our intent is to release quote information only
to you. We will not give your data to ANY other person or group for sales, marketing,
or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to
release us from any liability should this information be accidentally viewed by others.
Our intention is to maintain your complete privacy.
Yes, I Agree.
Please Send Me a Business Owner's Quote NOW!
Click Button Below When Done
Please Click Only Once . . . May take up to 30 seconds!
