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
*	Doctor visit copay:		Yes	No
*	Deductable:
*	Coinsurance:
*	Optional Coverage:
*	Prescription Card		Yes	No

	List all individuals (you, your spouse & dependents) you wish to cover:
	Name:
	Date of Birth:	/ /
	Age:
	Gender:		Male	Female
	Height:
	Weight:
	Tobacco User:		Yes	No

	Name:
	Date of Birth:	/ /
	Age:
	Gender:		Male	Female
	Height:
	Weight:
	Tobacco User:		Yes	No

	Name:
	Date of Birth:	/ /
	Age:
	Gender:		Male	Female
	Height:
	Weight:
	Tobacco User:		Yes	No