Welcome to D.W. Kendall Insurance Agency!
We are an Independent Insurance Agency serving the Miami Valley and West Milton for over 80 years! We offer Auto, Home, Farm, Business, Life, Health and Long Term Care Insurance Protection!
We're Independent - We Work For You!
Quote Forms:
Service Forms:
Long Term Care Insurance Quote
First & Last Name:
Street Address:
City, State & Zip:
E-Mail Address:
Telephone:
Fax:
Current Insurance Information
Insurance Company Name:
Co-Insurance Needed:
80/20 to $5,000
80/20 to $10,000
50/50 to $2,500
50/50 to $5,000
Don't Know
Deductible:
Don't Know
$250
$500
$1,000
$1,500
$2,000
$5,000
Co-Payment:
$5
$10
$15
$20
Interested in Additional
Coverage? Please List:
Self
Name:
Date of Birth
Sex:
Martial Status:
Height/Weight:
Tobacco Use?
Cancer or Diabetes?
Heart or HBP?
Yes
No
Describe any health problems you
have (had) & prescriptions:
Spouse
Child #1
Name:
Date of Birth
Sex:
Martial Status:
Height/Weight:
Tobacco Use?
Cancer or Diabetes?
Heart or HBP?
Yes
No
Describe any health problems you
have (had) & prescriptions:
Child #1
Child #2
Name:
Date of Birth
Sex:
Martial Status:
Height/Weight:
Tobacco Use?
Cancer or Diabetes?
Heart or HBP?
Yes
No
Describe any health problems you
have (had) & prescriptions:
Additional Comments:
