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Coverage Amount:*
Term Length*
Date of Birth:*
Weight: (pounds)*
Are you a US citizen?*
Are you a permanent US resident?*
If No, please explain:
Have you used any tobacco, nicotine, or vape products in the past 5 years?*
What type of product?
When was last use?
Have you ever been diagnosed or treated for any of these health issues? (Check all that apply)
How is your blood pressure being treated? Is it under control? When was it diagnosed?
How is your cholesterol being treated? Is it under control? Do you know your last reading? When was it diagnosed?
What type of cancer? When was it diagnosed? What was the stage/grade? How was it treated? How have follow ups been since treatment?
Heart/Liver/Kidney Condition: What were you diagnosed with? How is/was it treated? Have you had any surgerites? What was date of diagnosis and date of treatments? How have follow ups been since treatment?
Do you have Type 1 or Type 2 diabetes? When was it diagnosed? If Type 1, what was your last A1C reading? What medications do you take?
Anxiety/Depression - What condition have you been diagnosed with? Date of diagnosis? What medications do you take?
Alcohol or Drug Abuse - What condition? Date of diagnosis? How long sober? Have you completed any programs? Any relapses?
Please list all medications that you take that you have not already mentioned. Include the reason for taking the medication.

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Phone: 1-800-444-8376

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