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Get more life insurance coverage while paying less in premiums.
1) Date of Birth:
2) Gender Male Female
3) Height
4) Weight:
5) Nicotine Use:
6) Coverage Amount:
7) Term Period:
8) Rating Predictor:
Health Questionnaire
9) Are you currently taking any medications? Yes No  
  * If yes, what and why?
10) Have you been declined for life or health insurance in the last 5 years? Yes No
11) In the last 5 years have you had a felony, misdemeanor, drivers license suspended or revoked? Yes No
* If Yes, Check the following



12) Do you participate in any hazardous activities? Yes No

* If yes, Check the following








13) Have you ever had or been told you have? Yes No

* If yes, Check the following



















14) Any other health conditions not mentioned? Yes No
* If yes, please specify.