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Proposed Insured
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Risk Evaluation
If answer to question is not known, please leave blank.
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1a.
Do you have a history of alcohol or substance (drug) abuse?
If no check P+ and go to question 2, If yes go to question 1b.
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1b.
Has there been any abuse in the past 10 years?
If no check P and go to question 2, If yes check S and go to question 2.
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2a.
Have you had any DUIs in the past 5 years?
If no check P+ and go to question 3, If yes go to question 2b.
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2b.
Have you had any DUIs in the past 3 years?
If no check S+ and go to question 2, If yes check S and go to question 2.
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3.
Have you had more than two motor vehicle moving violations in the past three years?
If no check P+ and go to question 4, If yes check S+ go to question 4.
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4a.
Has either parent or a sibling had a history of cardiovascular disease or cancer before age 60?
If no check P+ and go to question 5, If yes go to question 4b.
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4b.
Has either parent died as a result of cardiovascular disease or cancer before age 60?
If no check P and go to question 5, If yes go to question 4c.
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4c.
Have both parents died as a result of cardiovascular disease before age 60?
If no check S+ and go to question 5, If yes check S and go to question 5
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5.
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6a.
Have you used any nicotine-based products in the past 36 months?
If no check P+ and continue to next section, If yes go to question 6b.
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6b.
Have you used any nicotine-based products in the past 24 months?
If no check P and continue to next section, If yes go to question 6c.
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6c.
Have you used any nicotine-based products in the past 12 months?
If no check S+ and continue to next section, If yes check PT if answers from 1 to 4 are all P/P+, otherwise, check ST
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Proposed Insured Information
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Term Period
Billing Frequency
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Gender
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Replacing existing policy?
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Is this for a business purpose?
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Date to Save Age?
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Waiver of Premium?
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