(724) 465-4261 Indiana, PA

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Insured Information

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Gender
Male Female

Tobacco Use?
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Spouse Name

Date of Birth

Gender
Male Female

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Child 1

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Gender
Male Female

Child 2

Date of Birth *

Gender
Male Female

Child 3

Date of Birth *

Gender
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Amount of Death Benefit

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Use Tobacco
Yes No

Gender
Male Female

Date of Birth

Height

Weight

List medications and reasons

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William G Mechling Insurance Agency | 1359 Philadelphia Street | Indiana, PA 15701 | (800) 401-4261 | (724) 465-4261

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