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:
	Daily Benefit:
	Include Home Health Care Coverage?		Yes	No
	Include Compound Inflation Rider Coverage?		Yes	No

	Spouse/Companion Information:
	Relationship:		Spouse	Companion
	Name:
	Gender:		Male	Female
	Date of Birth:	/ /