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Low Life Insurance Rates & Great Service

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Great! How many people will be on this policy?

What is your gender?

What is your birth date?

What is your marital status?

What is your work status?

What is your height?

What is your weight?

What type of coverage do you need?

Do you use tobacco?

Do you have relatives with heart disease or cancer?

Do you have a hazardous hobby/occupation?

Have you ever been diagnosed with the following?(check any that apply)

Have you been hospitalized in the last 5 years?

Have you been declined insurance in the last 5 years?

Do you take one or more prescription medications?

Have you had a dui/dwi in the last 5 years?

What is your full name?

What is your email address?

What is your phone number?

One
Two
Three
Four
More Than Four
Male
Female
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Married
Unmarried
Employed
Government
Housewife/Husband
Retired
Student Living w/ Parents
Stud. Not Living w/ Parents
Unemployed
Military
Less Than 4ftTaller Than 8 Feet
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Less Than 50 lbsMore Than 500 lbs
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Term (most popular)
Whole Life
Universal Life
Variable Life
Not Sure
Yes
No
Yes
No
Yes
No
None Of These
Heart Problem
Asthma
Blood Pressure
Depression or Anxiety
Cancer
Stroke
Diabetes
Cholesterol
AIDS/HIV
Alcohol or Substance Abuse
Other Major Illness
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Yes
No
Yes
No
Yes
No
Yes
No
Continue
Continue
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