Celentano Insurance Agency - Affordable Life, Health, Accident Insurance

The Celentano Insurance Agency, Inc. is a Licensed Broker and General Insurance Agent. Call or visit us at:

85 Main Street
Rowley, MA 01969
(978) 432-1146
info@celentanoinsurance.com

Use this form to receive a free, no-obligation, quote.
For an explanation of terms, go to our Glossary .

Type of Insurance
Life Insurance Type Term Universal Variable Life	Health Insurance Type: Medical Dental	Amount
Personal Information
Email	Phone	Cell Phone
First name Last name
Man Woman	Age
Health Insurance Type: History
Family History
Have you or anyone in your family ever had a cardiac condition before the age of 60? Yes No If yes, please provide details - type and when	Have you or anyone in your family ever had cancer before the age of 60? Yes No If yes, please provide details
Personal History
Have you ever smoked? Yes No If Yes: Currently Stopped within last 5 years Stopped more than 5 years ago	Please list medications you are taking: For blood pressure For high cholesterol List any other prescription drugs here
Do you currently have health or life insurance? Yes No If yes, what type and company:	Depending on your answers to these questions, we may need to contact you by telephone for additional information.
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