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Birthday (mm/dd/yy)   19
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Are you married? Yes     No 
Do you smoke? Yes     No 
Are you diabetic? Yes     No 
Are you insulin-dependent? Yes     No 
Do you use:   cane
  walker
  wheel chair
If you use other medical
equipment, please describe
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If you've required assistance with your everyday activities in the past 2 years please explain.
(otherwise, leave blank)
 
In the past 5 years, have you:   been confined to a hospital/nursing home
  had home care
  had long term care
  received rehabilitation
If you have any particular health problems, please describe
(otherwise, leave blank)
 
Would you like an additional quote?  Life Insurance
 Annuity (Retirement Vehicle)
 Disability Insurance
 Health Insurance
 Group Health Insurance
 Auto Insurance
 Homeowners Insurance
 Home Loans

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