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Aenean nonummy hendrerit mauris phasellus porta. Fusce suscipit varius mi. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur.

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Aenean nonummy hendrerit mauris phasellus porta. Fusce suscipit varius mi. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur.

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Free Evaluation Questionnaire

Contact Information

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Policy Information

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(approximate)
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Health Overview

Please check the most accurate description for the insured's lifestyle.

EXCELLENT Insured lives an active and independent lifestyle, may exercise regularly, travel, work, etc.
GOOD Insured lives a fairly active and independent lifestyle, may exercise intermittently, travel, work, etc.
FAIR Insured lives an average lifestyle primarily independent but with some minor assistance from friends and family.
POOR Insured lives an active and independent lifestyle, may exercise regularly, travel, work, etc.
SERIOUS Insured lives with independence, but does require some assistance and supervision.
TERMINAL Insured has terminal condition that may result in a life expectancy of 24 months or less.
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Health Conditions

Please check any of the following medical condition that apply to the insured.

  • Tobacco Use
  • Elevated Cholesterol
  • Asthma
  • Arthritis
  • Cancer Remission (5+yrs)
  • Osteoporosis
  • Overweight
  • Underweight
  • One TIA
  • Multiple TIAs
  • Hypertension
  • Ulcers
  • Hepatitis C
  • Poorly Controlled Hypertension or Diabetes
  • Parkinson Disease
  • Dementia
  • Diabetes (Type II)
  • Heart Failure
  • Coronary Artery Disease
  • COPD
  • Stroke (CVA)
  • Heart Attack
  • Lupus
  • Emphysema
  • Cancer (current/recurring)
  • Cirrhosis
  • Peripheral Vascular Disease
  • Valve Replacement or Repair
  • Atrial Fibrillation
  • Short-Term Memory Loss
  • Anemia
  • Renal Insufficiency
  • Cardic Arrhythmia
  • Sleep Apnea
  • Alzheimer's Disease
  • Aneurysm
  • Coronary Bypass
  • Multiple Sclerosis
  • Pacemaker
  • ALS
  • Organ Transplant
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