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Gender
Female
Male
Any tobacco, nicotine, marijuana, vape or tobacco substitute use?
Non in the last 5 years
Non in the last 4 years
Non in the last 3 years
Non in the last 2 years
Non in the last year
Last 12 month, Cigarette
Last 12 month, Marijuana
Last 12 month, Cigarette & Marijuana
Have you ever been rated up or declined by any life insurance company?
Yes
No
Do you have any parents or siblings who, prior to age 60, have been diagnosed with or died from cardiovascular, heart or coronary artery disease, stroke or cancer?
Yes
No
Have any medical tests or procedures been ordered or recommended that you have not yet completed?
Yes
No
Do you work at a paying job (employed or self-employed) at least 30 hours per week?
Yes
No
Have you been diagnosed with any medical conditions in the last 10 years or taken any prescription medications (including from a dentist) in the past 3 years?
Yes
No
Do you have any bankruptcy history?
Yes
No
Are you a U.S. Citizen?
Yes
No
Do you intend to travel to any country rated 3 or 4 on the U.S. State Department's Travel Advisory list?
Yes
No
Do you participate in hazardous activities or occupations (aviation, racing, scuba diving, skydiving, rock climbing, etc.)?
Yes
No
Do you have any criminal conviction history or law enforcement infractions?
Yes
No
Within the last 5 years, have you received 3 or more moving violations or been convicted of driving while under the influence (DUI)?
Yes
No
Are you now receiving disability payments or government assistance such as food stamps, WIC or Medicaid?
Yes
No
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