| State: |
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| Date of Birth: |
/ / 19 |
| Gender: |
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| Are you a US Citizen? |
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| What is your height? |
ft
in
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| What is your weight? |
lbs |
| Tobacco/Nicotene use: |
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| Requested amount of coverage: |
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| Guaranteed level term: |
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| Premium paid: |
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Health
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| Are you presently taking medication, or does your blood pressure exceed 135/80? |
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Are you presently taking medication for cholesterol, or does your cholesterol exceed 210? |
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Have any of your parents or siblings been diagnosed with or died from Cancer or Heart Disease before age 60? |
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Have you ever received medical advice or treatment for any of the following:
- Alcoholism
- Anxiety
- Cancer (not basal cell)
- Depression
- Diabetes
- Drug Abuse
- Epilepsy
- Heart Disease
- Multiple Sclerosis
- Respiratory Disorder
- Sleep Apnea
- Stroke
- Ulcerative Colitis or Lletis
- Vascular Disease
- Other serious medical condition
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Have you been hospitalized overnight in the last 5 years? |
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Have you had any DUI or other major violations in the last 2 years? |
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Contact Information
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| First Name: |
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| Last Name: |
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| Day Phone: |
() - x |
| Evening Phone: |
() - |
| Best time to call: |
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| E-Mail Address: |
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