Mancini Insurance
Agency
11269 Perry Hwy. #300
Wexford, PA 15090
Phone: 724-933-8637
Fax: 724-933-8600
Underwriting Information:
Name of Proposed Insured:
Enter Proposed Insured's Birthdate:
Sex (M/F):
Do You Smoke?:
Height:
Weight:
Spouse's Information: (Leave Blank if you do NOT want Spouse Coverage)
Name of Spouse:
Enter Spouse's Birthdate:
Sex (M/F):
Do You Smoke?:
Spouse Height:
Spouse Weight:
Coverages:
Amount of Coverage Desired?
Type of Life Coverage Desired?
TERM = Pays death benefit only - This is lowest cost for coverage.
UNIVERSAL LIFE = Has savings aspect in addition to providing death benefit.
OTHER = Would be mortgage protection, whole life, no-exam life, etc.
Years of Level Premium, if selecting term life.
List Any Health Problems:
Reason for Buying Life Insurance:
Send my quotation via:
E-Mail Fax Regular Mail
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