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Dale Mancini:
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andautoinsurance.com

Mancini Insurance
Agency
11269 Perry Hwy. #300
Wexford, PA 15090
Phone: 724-933-8637
Fax: 724-933-8600

Mancini insurance guarantees your satisfaction!

On-Line RV & Motorhome Insurance Quote Form One Simple Form - takes only 2-3 Minutes! YOUR PERSONAL DATA:
Your Name:
Street Address:
City:
State: (Must be Pennsylvania)
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):

Marital Status: Single Married	Homeowner? Yes No

Currently Insured? (If yes, list carrier, and # of years continuous. If no, type NONE)


DRIVER INFORMATION #1
Name:		Birthdate:
Sex:		# Years U.S. Auto License:
Driver License Number (REQUIRED by carriers to offer rate)
Number & Type of Accidents within last 3 years:		Number & Type of MINOR Cites within last 3 years:
Number & Type of MAJOR Cites within last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	Comments or Remarks?

DRIVER INFORMATION #2 (if none, leave blank)
Name:		Birthdate:
Sex:		# Years U.S. Auto License:
Driver License Number (REQUIRED by carriers to offer rate)
Number & Type of Accidents within last 3 years:		Number & Type of MINOR Cites within last 3 years:
Number & Type of MAJOR Cites within last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	Comments or Remarks?

R.V. #1 INFORMATION
Year of vehicle:		Make & Model:
Type (mobile/motor home, trailer, etc.):		Length in Feet:
Annual Mileage:		Value $:
List Special Equipment & Values (i.e., stove, refrigerator, special features, etc.)
R.V. #1 COVERAGES:
Limits of Liability:	$25/50 BI / 15 PD $50/100 BI / 50 PD $100/300 BI / 50 PD

Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Do you want Medical Coverage?	Yes No	Uninsured Motorists?	Yes No

R.V. #2 INFORMATION
Year of vehicle:		Make & Model:
Type (mobile/motor home, trailer, etc.):		Length in Feet:
Annual Mileage:		Value $:
List Special Equipment & Values (i.e., stove, refrigerator, special features, etc.)
R.V. #2 COVERAGES:
Limits of Liability:	$25/50 BI / 15 PD $50/100 BI / 50 PD $100/300 BI / 50 PD

Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Do you want Medical Coverage?	Yes No	Uninsured Motorists?	Yes No


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