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Home Insurance

Auto

Life Insurance
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