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Critical Iillness Insurance
Term Life Insurance
No Medical Insurance
Whole Life Insurance
Universal Life Insurance
Seniors Life Insurance
Funeral Coverage
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Type of Insurance
Type of Insurance
Term Life Insurance
No Medical Life Insurance
Seniors Life Insurance
Funeral Expenses Coverage
Mortgage Life Insurance
Term 100 Life Insurance
Universal Life Insurance
Whole Life Insurance
Amount of Insurance
Amount of Insurance
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
$55,000
$60,000
$65,000
$70,000
$75,000
$80,000
$85,000
$90,000
$95,000
$100,000
$125,000
$150,000
$175,000
$200,000
$225,000
$250,000
$275,000
$300,000
$325,000
$350,000
$375,000
$400,000
$425,000
$450,000
$475,000
$500,000
Gender
Male
Female
Date of Birth
DD
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
MM
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
YYYY
YYYY
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
First Name
Last Name
Smoker?
Yes
No
Phone Number
Email
No. & Street
Postal Code
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