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Height(Feets)

Height(Inches)

Weight(Lbs)

Occupation

Income($)

Gender

Date Of Birth

Do You Have Health Insurance ?

Insurance Company Name

Insurance Policy Start Date

Insurance Policy End Date

Your Marital Status ?

House Hold Size?

Heart Circulation Problems/HBP/Stroke

Lung Disorder/Asthma:

Cancer (incl. skin)

Diabetes: diet control/oral meds/insulin?

AIDS/ARC?

Mental/Nervous/ADD?

Alcohol/Drug Disorder?

Medical expense of $5000+ in the last year?

Pregnancy/Disability?

Hazardous Hobbies ?

Mountain-climbing / scuba diving / Other ?

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You Personal Details

You Personal Details

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