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Life Quote
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Life Quote
Do you currently have life insurance?
Yes
No
What is your gender?
Male
Female
Have you used tobacco products within the last 12 months?
Yes
No
Do you want coverage for?
Final Expense
Term Life
Whole Life
Requested Coverage Amount
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
$55,000
$60,000
$65,000
$70,000
$75,000
$80,000
$85,000
$90,000
$100,000
$105,000
$110,000
$115,000
$120,000
$125,000
$130,000
$135,000
$140,000
$145,000
$150,000
$155,000
$160,000
$165,000
$170,000
$175,000
$180,000
$185,000
$190,000
$195,000
$200,000
$205,000
$210,000
$215,000
$220,000
$230,000
$235,000
$240,000
$245,000
$250,000
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What is your zip code?
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What is your date of birth?
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What is your height?
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
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What is your weight (lbs)?
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What is your job status?
Currently Employed
Retired
On Disability
Homemaker / Other
Are you currently taking any prescription medication?
Yes
No
Have you been treated for or prescribed medicine for :
Alzheimer's Disease
Lou Gehrig's disease
Cystic Fibrosis
Cystic Lung Disease
Dementia
Hepatitis B/C/D
HIV/AIDS
Hydrocephalus
Multiple Sclerosis
Parkinson's Disease
Paraplegia
Quadriplegia
Schizophrenia
Suicide Attempt
Silicosis
STD/STIs
Yes
No
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