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Call us! 620-792-4515
Toll Free: 866-792-4515

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Request a Quote - Life Insurance

Just fill out the form and "submit", you will receive your free life insurance quote.

Information provided will be kept confidential and used for quoting purposes only. All quotes are based on the information given and are subject to change upon further underwriting. Coverage can not be bound via e-mail or internet service.

 

1911 Lakin Avenue
Great Bend, KS 67530

Phone: 620-792-4515
Fax: 620-793-3311

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Applicant Information

Name:

Street Address:

City:

  State:        ZIP:

County:

E-Mail Address:

 

Home Phone:

 Work:

Coverage Information - Applicant #1

Name:  
Gender: Male  Female

Age: 
Height:

Weight:
Do you smoke? Yes  No
Occupation:
Type of Policy Desired: Term Insurance
 Whole Life Insurance

Term Insurance: Term insurance is temporary. The death benefit of a term life insurance policy is payable to the beneficiary at the death of the insured, provided death occurs with a period (i.e. 1,5,10 years) specified by the policy.

Whole Life Insurance: The death benefit of whole life insurance is payable to the beneficiary at the death of the insured whenever that occurs provided the insured is less than age 100. Premiums may be payable for a specified number of years or for life.

Amount of Coverage
Specified period (term in years) of protection (for term insurance only)

Purpose(s) of this Life Insurance Policy:

Mortgage Protection - Pay off the remaining mortgage on your home.
Final Expenses - Funeral Home and Burial Costs.
Family Income - Compensate survivors for loss of income.
College Fund
Estate Liquidity
Retirement (savings)

Coverage Information - Applicant #2

Name:  
Gender: Male  Female

Age: 
Height:

Weight:
Do you smoke? Yes  No
Occupation:
Type of Policy Desired: Term Insurance
 Whole Life Insurance

Term Insurance: Term insurance is temporary. The death benefit of a term life insurance policy is payable to the beneficiary at the death of the insured, provided death occurs with a period (i.e. 1,5,10 years) specified by the policy.

Whole Life Insurance: The death benefit of whole life insurance is payable to the beneficiary at the death of the insured whenever that occurs provided the insured is less than age 100. Premiums may be payable for a specified number of years or for life.

Amount of Coverage
Specified period (term in years) of protection (for term insurance only)

Purpose(s) of this Life Insurance Policy: Mortgage Protection - Pay off the remaining mortgage on your home.
Final Expenses - Funeral Home and Burial Costs.
Family Income - Compensate survivors for loss of income.
College Fund
Estate Liquidity
Retirement (savings)

 

 

 

Phone: 620-792-4515
Toll Free: 866-792-4915
Fax: 620-793-3311

1911 Lakin Avenue
P.O. Box 1910
Great Bend, KS 67530-1910

www.gossins.com
Email Goss Insurance

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