LIFE INSURANCE REQUEST FORM

LIFE INSURANCE Inquiry Form
(Pennsylvania Only)

To receive a quote, please fill out the form below......

Name:
Address:
City, St., Zip:
Phone Number(s):
E-Mail Address:

Individuals to be insured....

1	NAME	SEX	BIRTH DATE	SMOKER/NON	DEATH BENEFIT
				Height: Weight:	$
	Policy Type:		Occupation:

2	NAME	SEX	BIRTH DATE	SMOKER/NON	DEATH BENEFIT
				Height: Weight:	$
	Policy Type:		Occupation:

3	NAME	SEX	BIRTH DATE	SMOKER/NON	DEATH BENEFIT
				Height: Weight:	$
	Policy Type:		Occupation:

4	NAME	SEX	BIRTH DATE	SMOKER/NON	DEATH BENEFIT
				Height: Weight:	$
	Policy Type:		Occupation:

5	NAME	SEX	BIRTH DATE	SMOKER/NON	DEATH BENEFIT
				Height: Weight:	$
	Policy Type:		Occupation:

6	NAME	SEX	BIRTH DATE	SMOKER/NON	DEATH BENEFIT
				Height: Weight:	$
	Policy Type:		Occupation:

7	NAME	SEX	BIRTH DATE	SMOKER/NON	DEATH BENEFIT
				Height: Weight:	$
	Policy Type:		Occupation:

Does anyone have health problems? Yes No
If "Yes", please describe....

Life insurance has many uses. It can be used for:

Retirement Income

Pension Benefits Maximization

Family Security

and many more financial ideas

Private Pension Plans

Business Arrangements

Tax-Deductible College Education Funding

M c G R A T H I N S U R A N C E G R O U P

4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474 Fax: (724) 327-7911
Toll Free: 1-800-977-2999