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Your Age* |
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Sex, Gender |
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Spouses Age if applying |
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Medical History? Blood Pressure,
Back or Spinal Problems,
Chronic Illnesses, Pregnancies, etc?
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What medications, dosage, reason are you on? |
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Do you have any restrictions on daily activities?
Are you fully able to care for yourself? Explain |
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When did you want your new coverage to start? |
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We are REQUIRED
to ask the following financial questions when completing an application
- so let's get it out of the way now. It will also help us and you
- select the best options for you. |
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How will you pay each year's premiums?* |
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What is your Annual Income?* |
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When do you want benefits to start? 1st day of care, 30
day wait, 90 day wait, 6 months - the longer the wait for benefits to
start - the lower the premiums. |
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