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Term Life Insurance Quote First & Last Name:   Street Address:   City, State & Zip:   E-Mail Address:   Telephone:   Fax:   Self Name: Date of Birth Sex: Martial Status: Height/Weight: Tobacco Use? Cancer or Diabetes? Heart or HBP? Yes No Amt. of Coverage $ Type of Coverage Disability Income Long Term Care Term Whole Universal Yes No Yes No Describe any health problems you have (had) & prescriptions: Spouse Name: Date of Birth Sex: Martial Status: Height/Weight: Tobacco Use? Cancer or Diabetes? Heart or HBP? Yes No Amt. of Coverage $ Type of Coverage Disability Income Long Term Care Term Whole Universal Yes No Yes No Describe any health problems you have (had) & prescriptions: Children Name: Date of Birth Amt. of Coverage $ Type of Coverage Term Whole Universal Term Whole Universal Term Whole Universal Additional Comments:

106 S. Penn Oberlin, Ks 67749 Tel: (785) 475-3310 Fax: (785) 475-8965 117 N. Kansas Norton, KS 67654 Toll Free: 866-484-6236 Tel: 785-877-4016 Fax: 785-874-4832 PO Box 235 101 Front St. Winona, KS 67764 Tel: (785) 846-7476 Fax: (785) 846-7479