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Jeff Mangelli

Jeff Mangelli

Location:
7451 Auburn Blvd # B
Citrus Heights, CA
95610

Phone: (916) 728-4050
Fax: (916) 728-4070

CA Lic#: 0C22228

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First Name
Last Name
Address 1
Address 2
City
State
Zip Code
Daytime Phone
Evening Phone
Email Address
Do you own your own home?	Yes No
Are you currently insured? If No, please skip the next two questions	Yes No
Current company?
Expiration Date	/ /

	Driver 1	Driver 2	Driver 3
Name
Date of Birth
Sex
Marital Status
# of Years Licensed
# of Tickets in the Past 5 Years	0 1 2 3+	0 1 2 3+	0 1 2 3+
# of Accidents in the Past 5 Years	0 1 2 3+	0 1 2 3+	0 1 2 3+
Would you like a FREE copy of your MVR?	Yes No	Yes No	Yes No

	Car 1	Car 2	Car 3
Year
Make
Model (be specific)
2 door/4 door
# cylinders
Car is driven for
Miles to work one way
Annual Mileage over 20,000	Yes No	Yes No	Yes No
Safety Features	1 Air Bag Dual Air Bags Anti-Lock Brakes Automatic Seatbelts Passive Alarm Daytime Lights	1 Air Bag Dual Air Bags Anti-Lock Brakes Automatic Seatbelts Passive Alarm Daytime Lights	1 Air Bag Dual Air Bags Anti-Lock Brakes Automatic Seatbelts Passive Alarm Daytime Lights
Vehicle Identification No.
Vehicle please select
Towing

Liability Coverage	Property Damage

Deductible: Collision	Deductible: Comprehensive

Deductible: Rental Car per day for 30 days
Uninsured Motorist	Medical Payments