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Affordable Health 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:

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