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Amt. of Coverage
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Long Term Care
$

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Spouse's Information
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Height: Weight:
Amt. of Coverage
Type of Coverage
Disability Income
Long Term Care
$

Please Check if any of the following apply to your spouse:

Cancer:
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Diabetes:
High Blood Pressure:
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Describe any health problems and/or prescriptions:

Children
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$
$
$
$

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Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.


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Assurant



JWB INSURANCE
Kelly A. Smith, owner/agent
PO Box 877
324 East Highway, Suite B
Holdenville, OK  74848
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Phone: 405-379-3395
Fax: 405-379-2127
Toll Free: 800-979-3395
Emergency: 405-380-3178
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