Logo.gif (11507 bytes)    166 Winthrop Ave. Revere MA 02151 781-284-8783, fax 781-289-4451

Lattanzi Insurance Agency is licensed to sell insurance in the state of Massachusetts.   If you are not a resident of Massachusetts, or if the exposure you wish to insure is not in the state, we will be unable to provide you a quote.  Quotes provided from this form are estimates only.  These quotes are subject to change upon formal application and additional information obtained or revised.  Lattanzi Insurance Agency accepts no responsibility for electronic piracy, etc., when any information is submitted electronically.  Completing and submitting the following information indicates understanding and acceptance of these terms and conditions.  Submission of application information does not obligate you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Life Insurance Quote Form

wpe8.gif (2088 bytes) for a quick comparison quote, fax your current policy to
(781) 289-4451 or email Peter@Lattanziinsurance.com

Please provide the following contact information:

Name
Address
City
State (Mass. Only) Zip
Contact Via
Work phone
Home phone
Fax
Email

Please provide the following information for each person to be quoted:

   Person #1
First name
Age Sex Smoker
Height Weight
Occupation
Type of insurance policy to be quoted
Amount
If Term, period desired

(Optional)Person #1: Please check if you ever had indications of any of the following:

Heart disease
Cancer
HIV
Diabetes
High cholesterol
High blood pressure

   Person #2
First name
Age Sex Smoker
Height Weight
Occupation
Type of insurance policy to be quoted
Amount
If Term, period desired

(Optional)Person #2: Please check if you ever had indications of any of the following:

Heart disease
Cancer
HIV
Diabetes
High cholesterol
High blood pressure

If a child rider is desired, please indicate the amount of coverage desired:

       Rider amount:

Any other questions or concerns?