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Full Name
Email
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What state do you live in?
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What is your height
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What is your weight approximately?
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What is your gender?
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Male
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What is your Age?
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Are you a legal resident of the United States?
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Have you used any tobacco products in the past 24 months?
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Yes
No
Are you married or currently living with your spouse?
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Yes
No
How many children are in the household,If any?
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0
1
2
3
4
5
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Who are you looking to get coverage for? (Select all that apply)
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Myself
Spouse
Children
Select all that fit what you are most interested in?
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Burial Insurance
Living Benefits
Retirement
Leave a legacy to family
Covering mortgage
Which best describes where you receive your monthly income from?
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Select one from the following
Employment
Retirement
Social Security
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What is your estimated gross monthly income?
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Below $1,500
$1,500-$3,000
$3,000-$4,500
$4,500-$6,000
Over $6,000
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What is a comfortable amount you are looking to contribute monthly to a plan that best fits what you are looking for?
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Select one from the following
Below $100
$100-$250
$250-$500
Over $500
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Are you currently contributing or have funds stuck in a 401K?
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Yes
No
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