Get a Quote - Individual Health/Life/Disability
 

Please enter the following information and click "Submit Quote Request" at bottom.

Individual Information
Full Name:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Phone:
Email Address:
Date of Birth (mm/dd/yyyy):
Use Tobacco? Yes No
Gender: Male  Female
Height (example: 5' 8"):
Weight (lbs):
   
Life Insurance Information
Amount of Death Benefit:
Describe any Pre-existing Health Conditions:
List below any medication, including dosage and frequency:
Note any other pertinent information or requests for coverage:
   
Spouse
Spouse to be Insured? Yes No
If Yes, provide the following spousal information:
Full Name:
Spouse Date of Birth (mm/dd/yyyy):
Spouse Use Tobacco? Yes No
Spouse Height (example: 5' 8"):
Spouse Weight (lbs):
   
Child(ren) Information
Children? Yes No
If Yes, provide the following information:
Date of Birth (mm/dd/yyyy) Male  Female
Date of Birth (mm/dd/yyyy) Male  Female
Date of Birth (mm/dd/yyyy) Male  Female
   
Disability Insurance Information
Occupation:
Duties:
Earnings $:
Weekly Monthly Yearly
   

 

 

 

 
Franklin Insurance

104 13th Street
Franklin, PA 16323
(814) 432-4523 - (800) 346-8714
(814) 432-8644 (fax)

  Titusville Insurance

314 South Franklin Street, Suite D-1
Titusville, PA 16354
(814) 827-8888
(814) 827-3557 (fax)

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