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Coverage Amount
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Length Of Coverage
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Your Personalized Quotes
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Height and weight
feet
inches
lbs
Current & Past Smoking/Tobacco use
Additional Smoking/Tobacco questions
Cigarettes:
How long has it been since you last smoked a Cigarette?
On average, how many cigarettes per month do/did you smoke?
Cigars:
How long has it been since you last smoked a Cigar?
On average, how many cigars per month do/did you smoke?
Pipe:
How long has it been since you last smoked a Pipe?
Chewing Tobacco:
How long has it been since you use a Chewing Tobacco?
Nicotine Patches Or Gum:
How long has it been since you use Nicotine Patches Or Gum?
Blood Pressure & Cholesterol
Have you ever been treated for or taken medication for high blood pressure?
What is your systolic pressure?
What is your diastolic pressure?
Have you ever been treated for or taken medication for high cholesterol?
What is your cholesterol level?
What is your HDL ratio?
Driving
Have you ever had a drivers license?
Have you ever been convicted of drunken driving (DUI/DWI)?
Have you ever been convicted of reckless driving?
Have you license ever been revoked or suspended?
Have you ever had more than one accident?
during the last 6 months:
during last year, more than 6 months:
during last 2 years, more than 1 year:
during last 3 years, more than 2 years:
during last 4 years, more than 3 years:
Family History & Substance Abuse
Please indicate the total number of family members (parents of siblings) who have died from cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70:
Not including those who died, please indicate the total number of family members (parents or siblings) who have contracted cardiovascular disease (heart attacks and strokes), cancer, diabetes, or kidney disease before the age or 70:
Have you ever been treated for alcohol abuse?
If yes, the number of years since treatment:
Have you ever been treated for drug abuse?
If yes, the number of years since treatment:
Select a coverage starting point
Coverage Amount
${{face_amount.toString().replace(/\B(?=(\d{3})+(?!\d))/g, ",")}}
Length Of Coverage
{{(term==40) ? "40 years" : term + " years"}}
Your Personalized Quotes
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