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Personal Information

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Address Home Phone
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Preferred Contact Method Email   Phone



Personal Information Please enter information below for all to be covered.

 
Self
Spouse
Child #1
Child #2
Child #3
Name:
Self
Date of
Birth:
Sex:
M   F
M   F
M   F
M   F
M   F
Marital Status:
M   S
M   S
M   S
M   S
M   S
Occupation:



Tobacco Information Please enter information below for all to be covered.

Have you ever smoked or used tobacco products including cigarettes, cigars, pipes or chewing tobacco within the last 6 months?
 
Self
Spouse
Child #1
Child #2
Child #3
Yes No Yes No Yes No Yes No Yes No



Life Coverages

 
Self
Spouse
Child #1
Child #2
Child #3
Amount of
Coverage:
$
$
$
$
$
Type of
Coverage:
Term
Whole
Universal
Term
Whole
Universal
Term
Whole
Universal
Term
Whole
Universal
Term
Whole
Universal
Term
Length (Optional)
Disability
Income:
Y   N
Y   N
N/A
N/A
N/A
Long Term
Care:
Y   N
Y   N
N/A
N/A
N/A



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Johnston Fiss Insurance : Serving the personal & business insurance needs of Kansas since 1965. A Shawnee Mission KS based Insurance Agent