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Policy Requested:
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COBRA
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Discount Plan
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Short Term
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Personal:
What is your date of birth?
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What is your gender?
Male
Female
Other
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What is your occupation?
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Student not living with Parents
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What is your marital status?
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What is your education level?
Bachelors Degree
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None
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Who is the Applicant?
Myself
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Parent
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Currently employed?
Yes
No
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Currently student?
No
Yes
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Do you have a residence in the US?
Yes
No
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Height Foot
2
3
4
5
6
7
8
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Height Inch
0
1
2
3
4
5
6
7
8
9
10
11
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Weight in lbs
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BMI
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Household income in USD
below 30000
> 30000
> 45000
> 60000
> 75000
> 100000
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People in household
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Previously denied insurance?
No
Yes
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Prescriptions:
Do you have any prescriptions?
No
Yes
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Description of prescriptions
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Medical History:
Hospitalized before?
No
Yes
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You have ongoing medical treatments?
No
Yes
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Are you pregnant?
No
Yes
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Are you smoker?
No
Yes
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Are you alcohol abstain?
No
Yes
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Conditions:
Do you have any pre existing conditions?
No
Yes
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High Cholesterol
No
Yes
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Ulcers
No
Yes
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Vascular Disease
No
Yes
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AIDS / HIV
No
Yes
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Arthritis
No
Yes
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Asthma
No
Yes
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Kidney Disease
No
Yes
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Cancer
No
Yes
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Depression
No
Yes
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Diabetes
No
Yes
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Heart Disease
No
Yes
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Liver Disease
No
Yes
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Plumonary Disease
No
Yes
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Hepatitis
No
Yes
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High Blood Pressure
No
Yes
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Mental Illness
No
Yes
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Stroke
No
Yes
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Alzheimer
No
Yes
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Alcohol Abuse
No
Yes
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Drug Abuse
No
Yes
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Other
No
Yes
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Policy Current:
Are you currently insured?
No
Yes
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Current Insurance Company
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FinanceBox.com
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Horace Mann Insurance
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IDS
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Insurance.com
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Landmark American Insurance
Leader Insurance
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Peak Property and Casualty Insurance
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Physicians
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Premier
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Principal Financial
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Protective Life
Prudential Insurance Co.
RBC Liberty
Reliance Insurance
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Response Insurance
SAFECO
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Senior Market Sales
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Sentry
Shelter
St. Paul Insurance
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State and County Mutual Fire Insurance
State Farm
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The Ahbe Group
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TICO Insurance
TICO Insurance1
TIG Countrywide Insurance
Titan
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Unitrin Direct
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USA Benefits/Continental General
USAA
USF and G
Viking Insurance
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William Penn
Windsor Insurance
Woodlands Financial Group
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Other
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