(715) 849-2500 Wausau, WI

Advantage Insurance Services

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Insured Information

Name *

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Gender
Male Female

Tobacco Use?
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Spouse Name

Date of Birth

Gender
Male Female

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Child 1

Date of Birth *

Gender
Male Female

Child 2

Date of Birth *

Gender
Male Female

Child 3

Date of Birth *

Gender
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Amount of Death Benefit

Insured Information

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Use Tobacco
Yes No

Gender
Male Female

Date of Birth

Height

Weight

List medications and reasons

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Advantage Insurance Services | 1500 Grand Ave | Wausau, WI 54403 | (715) 849-2500

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