(928) 226-1611 Flagstaff, AZ

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Insured Information

Name *

Date of Birth *

Gender
Male Female

Tobacco Use?
Yes No

Phone Number *

Email *

Street Address *

City *

State *

Zip *

Spouse Name

Date of Birth

Gender
Male Female

Tobacco Use?
Yes No

Child 1

Date of Birth *

Gender
Male Female

Child 2

Date of Birth *

Gender
Male Female

Child 3

Date of Birth *

Gender
Male Female

Amount of Death Benefit

Insured Information

Insured Name *

Address *

City *

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Use Tobacco
Yes No

Gender
Male Female

Date of Birth

Height

Weight

List medications and reasons

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Dan Hakes Insurance Agency | 2501 N. Fourth Street, Suite 3 | Flagstaff, AZ 86004 | (928) 226-1611

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