Kansas Financial Resources

Contact Information

*	Name:
*	Address:
*	City:
*	State:
*	ZIP:
*	Work No.:
	Home No.:
	Fax No.:
*	Email Address:
*	Best time to contact:		Home	Office
*			AM	PM
	Date of Birth:	/ /
	Gender:		Male	Female
	Tobacco User:		Yes	No
	Height:
	Weight:
	Occupation:
	Current Annual Income:
	Is there disability coverage currently inforce?		Yes	No
	If yes how much and who is the current carrier?

	Desired benefit period
	Desired waiting/elimination period?