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First Name: *
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Last Name: *
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Street Address: *
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Suite/PO Box:
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City: *
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State: *
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Zip: *
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Phone: *
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Coverage Amount: *
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E-mail Address:
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1. Have you ever had a heart attack, angina, angioplasty, bypass surgery, chronic
kidney or liver disorder, emphysema, hepatitis C, internal cancer, insulin-dependent
diabetes, melanoma, or stroke? Are you HIV positive? *
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2. Have you ever been treated for high blood pressure or high cholesterol? Have
any of your natural parents or siblings died from coronary artery disease or cancer
prior to age 60? *
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3. Have you ever been treated for alcohol or drugs, asthma, colitis, Crohn's disease,
depression/mental disorder, epilepsy, heart murmur, or type II diabetes? Had a DUI,
reckless driving, or suspension in the past 5 years? Had more than two moving violations
in the past 3 years? *
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4. Have you used tobacco or nicotine products in the past 12 months? *
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5. What is your gender? *
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6. What is your Date of Birth? *
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7. What is your height? *
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8. What is your weight? *
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lbs
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lbs
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