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How old are you?

[{"by":1,"end":90,"start":17}]
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"18"
  • <18 years old
  • 90+ years old
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What is your gender?

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What is your marital status?

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What is your work status?

Employed
Government
Housewife/Husband
Retired
Student Living w/ Parents
Stud. Not Living w/ Parents
Unemployed
Military
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What is your height?

["4 Feet","4' 1 Inch","4' 2 Inches","4' 3 Inches","4' 4 Inches","4' 5 Inches","4' 6 Inches","4' 7 Inches","4' 8 Inches","4' 9 Inches","4' 10 Inches","4' 11 Inches","5 Feet","5' 1 Inch","5' 2 Inches","5' 3 Inches","5' 4 Inches","5' 5 Inches","5' 6 Inches","5' 7 Inches","5' 8 Inches","5' 9 Inches","5' 10 Inches","5' 11 Inches","6 Feet","6' 1 Inch","6' 2 Inches","6' 3 Inches","6' 4 Inches","6' 5 Inches","6' 6 Inches","6' 7 Inches","6' 8 Inches","6' 9 Inches","6' 10 Inches","6' 11 Inches","7 Feet","7' 1 Inch","7' 2 Inches","7' 3 Inches","7' 4 Inches","7' 5 Inches","7' 6 Inches","7' 7 Inches","7' 8 Inches","7' 9 Inches","7' 10 Inches","7' 11 Inches"]
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"15"
  • Less Than 4ft
  • Taller Than 8 Feet
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What is your weight?

["50-60 lbs.","61-70 lbs.","71-80 lbs.","81-90 lbs.","91-100 lbs.","101-110 lbs.","111-120 lbs.","121-130 lbs.","131-140 lbs.","141-150 lbs.","151-160 lbs.","161-170 lbs.","171-180 lbs.","181-190 lbs.","191-200 lbs.","201-225 lbs.","226-250 lbs.","251-275 lbs.","276-300 lbs.","301-350 lbs.","351-400 lbs.","401-450 lbs.","451-500 lbs."]
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"10"
  • Less Than 50 lbs
  • More Than 500 lbs
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What type of coverage do you need?

Term (most popular)
Whole Life
Universal Life
Variable Life
Not Sure
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What Is Your Annual Income?

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When Was Your Last Nicotine Usage?

Never used nicotine products
Within the last year
13-24 months ago
25-36 months ago
37-60 months ago
More than 60 months ago
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Have you had a DUI/DWI, reckless driving, or license suspension in the last 5 years? 

Yes
No
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How many prescription drugs are you currently taking?

0
1
2
3
4 or more
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Have you had a death in the family before the age of 60?

No early deaths
1 parent or sibling
2 or more parents/sibling
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Do you have any of the following health conditions?

Anxiety
High cholestrol
High blood pressure
Depression
Diabetes
None of the above
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Where are you located?

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What is your birth date?

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day
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year
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