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Height / Weight:

Date of Birth:

Tobacco Use:

Coverage Amount:

Length of Term:

State:

Gender:

Are you presently taking any prescribed medications for blood pressure, cholesterol or taking medications (oral or otherwise) for diabetes?

NoYes

Have either of your parents or any siblings died from cancer or heart disease prior to their age 60?

No Yes

Have you been treated for: stroke or heart disease? Are you on disability? Ever been declined coverage? Have you been treated for a threatening cancer within the past 5 years?

No Yes

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