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Required Information
* Coverage Amount
* Term Length
   
Additional Information Yes No
* Is this person a licensed pilot?
* Has this person ever been convicted of a DUI in the past 5 years?

* Has this person ever been convicted of a felony?

* Does this person engage in scuba diving, sky diving, rock climbing, motorized    racing, or any other hazardous avocation or occupation?

* Does this person have any immediate relatives who have ever had heart disease?
* Does this person have any immediate relatives who have ever had any form of cancer?
Check any of the following that the person to be quoted has been
diagnosed with (in the past 10 years):
AIDS/HIV Heart Disease Mental Illness
Alzheimer's Kidney Disease Pulmonary Disease
Cancer Liver Disease Stroke

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