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Policy Requested:

What coverage package do you wish?
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Personal:

What is your date of birth?
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What is your gender?
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What is your occupation?
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What is your marital status?
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What is your education level?
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Who is the Applicant?
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Currently employed?
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Currently student?
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Do you have a residence in the US?
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Height Foot
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Height Inch
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Weight in lbs
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BMI
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Household income in USD
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People in household
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Previously denied insurance?
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Prescriptions:

Do you have any prescriptions?
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Description of prescriptions
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Medical History:

Hospitalized before?
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You have ongoing medical treatments?
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Are you pregnant?
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Are you smoker?
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Are you alcohol abstain?
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Conditions:

Do you have any pre existing conditions?
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High Cholesterol
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Ulcers
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Vascular Disease
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AIDS / HIV
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Arthritis
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Asthma
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Kidney Disease
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Cancer
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Depression
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Diabetes
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Heart Disease
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Liver Disease
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Plumonary Disease
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Hepatitis
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High Blood Pressure
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Mental Illness
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Stroke
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Alzheimer
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Alcohol Abuse
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Drug Abuse
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Other
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Policy Current:

Are you currently insured?
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Current Insurance Company
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Insured since
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Insurance end
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