Health Information Needed

To help us evaluate the insurance needs of our members, please print, then fill out and return this health form by fax to 316-855-2216 (Shirley Voran).

1) What are you needing for health care coverage? _____________________________

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2) Do you have any conditions (past, present or anticipated) such as
diabetes, cancer, strokes, pregnancy, or disablity, etc. that would
need to be covered? Please describe.  Include a description of major
medical expenses (over $10,000) incurred in the last 12 months.

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