(503) 358-3481 PENDLETON, OR

Merle Johnson Insurance Agency

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Insured Information

Name *

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Tobacco Use?
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Phone Number *

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Male Female

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Child 1

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Gender
Male Female

Child 2

Date of Birth *

Gender
Male Female

Child 3

Date of Birth *

Gender
Male Female

Amount of Death Benefit

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Use Tobacco
Yes No

Gender
Male Female

Date of Birth

Height

Weight

List medications and reasons

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Merle Johnson Insurance Agency | 16 SE 9TH DR | PENDLETON, OR 97801 | (503) 358-3481

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