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Policy Criteria Questions

What is your height?:

What is your weight?:

Do you use tobacco products?:

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Do you currently have health insurance?:

Yes No

Do you have any pre-existing conditions?:

Are you an expectant parent?:

Yes No

Have you ever been denied health coverage?:

Yes No

Are you currently on Social Security or Disability?:

Yes No

Number of people in household:

Approximate Household Income:

Subsidy?:

Quote Information

First Name:

Last Name:

Street address:

City:

State:

ZIP code:

Email address:

Phone:

Birthdate:

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Policy Criteria Questions

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