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First Name:
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Birthdate: Gender: Male Female
Height: Weight:
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Health Status (check one):
Excellent (Trim, athletic, no medications)
Good (No infirmity or medications)
Fair (Taking medication or slightly overweight)
Poor (Describe problem in "Other comments")
Current medications, dosage, reason:

Have you ever used tobacco products?
No, I have never used tobacco
Yes, I currently use tobacco
Yes, but I quit over 1 year ago
Yes, but I quit over 3 years ago
Yes, but I quit over 5 years ago
Has a parent died before age 60?
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If so, at what age?

Cause of death?   
Other comments/questions:

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QuoteTermLife, Inc. - P.O. Box 871106
Canton, MI  48187

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