Questions? (877) 385-2224
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Agent's Name:   Address:
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Client Name 1: Client Name 2:
Date of Birth: Date of Birth:
Smoker? Smoker?
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Height: Height:
Weight: Weight:
Prescription meds, dose & condition taken for: Prescription meds, dose & condition taken for:
Previously declined? Previously declined?
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Carrier: Carrier:
Add'l history (e.g., # years since last smoked): More info (e.g., type of tobacco; treatments):
 
 
Toll Free (877) 385-2224

Kansas Offices:
Overland Park (913) 385-2224
Wichita (316) 263-2900

Missouri Offices:
Kansas City (816) 333-7132
Springfield (417) 833-4255
St. Louis (314) 453-0404
 
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