Cavallo and Signoriello Insurance Agency - Manfield, MA - Auto Insurance, Home Insurance and Commercial Insurance

Name: Address:

City: State: Zip:

Phone: E-Mail:

Best time to contact you: at:

Sex: Date of Birth: (MM/DD/YY)

Your Height: Feet Inches Your Weight: pounds

The coverage to be quoted will likely be:
New Coverage (I have none now)
Additional Coverage
Replacement of existing Coverage

I smoke no more than one pack of cigarettes per day.
I smoke more than one pack of cigarettes per day.

Are you a private pilot? Yes No
If yes, please explain type of rating, type of aircraft, total number of hours experience, and hours flown per year:

Do you engage in scuba diving, sky diving, rock climbing, motorized racing, or other hazardous avocation or occupation? Yes No
If yes, please explain in detail:

Have you been convicted of drunk driving or had your driver's license suspended or revoked in the past five years? Yes No
If yes, please explain in detail:

Have you been convicted of three or more moving violations in the past three years? Yes No

Have you ever been convicted of a felony? Yes No
If yes, please explain dates, charges, and details:

In the past 10 years, I have been advised regarding or been treated for:
Hypertension Heart Disease Cancer Diabetes
Stroke Alcohol or Drugs AIDS Other
If you checked any of the above, please explain:

Did any of your grandparents, parents or siblings have heart disease or cancer prior to age 65?
Yes No
If yes, please explain: