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Crop Insurance Quote Form First & Last Name:   Street Address:   City, State & Zip:   E-Mail Address:   Telephone:   Fax:   County:   Crop (s):   What type of coverage are you interested in?:   Select.. Yield Based Crop Hail Crop Revenue Coverage Catastrophic Coverage Revenue Assurance Please Indicate Production Crop Acres Yield Irrigated? Yes No Yes No Yes No Yes No Additional Information / comments that will assist us in your crop insurance quote:

106 S. Penn Oberlin, Ks 67749 Tel: (785) 475-3310 Fax: (785) 475-8965 117 N. Kansas Norton, KS 67654 Toll Free: 866-484-6236 Tel: 785-877-4016 Fax: 785-874-4832 PO Box 235 101 Front St. Winona, KS 67764 Tel: (785) 846-7476 Fax: (785) 846-7479