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Husband -- Personal Information

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Have you had an insurance exam in the past 60 days? Yes No

Wife -- Personal Information

Name: First: Last:

Date of Birth: Month: Day: Year:

Are you a smoker? Yes No

Have you used any nicotine in the past five years? Yes No

Have you been hospitalized in the past 5 years or are you currently taking medication?
Yes No       If yes, please explain in the box below or call our office at 800-233-6481:

Have you had an insurance exam in the past 60 days? Yes No

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