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Home Number:	xxx-xxx-xxxx
Work Number:	xxx-xxx-xxxx
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Birthdate:	-- January February March April May June July August September October November December Month   -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day   ---- 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 Year
Sex:	Male   Female
Have you used Tobacco in the past 12 months?:	Never Used No cigarettes in past 12 months No nicotine or tobacco in last 12 months No nicotine or tobacco in last 3 years Smokes cigarettes Uses some form of nicotine or tobacco
Describe your Health: Also Height & Weight	Regular   Regular Plus Preferred Preferred Plus
Initial Level Insurance Period:	5 Year - Guaranteed Only 5 Year 10 Year - Guaranteed Only 10 Year 15 Year - Guaranteed Only 15 Year 20 Year - Guaranteed Only 20 Year 25 Year - Guaranteed Only 25 Year 30 Year - Guaranteed Only 30 Year
Amount of Insurance:	$50,000  $75,000  $100,000  $150,000  $200,000  $250,000  $300,000  $350,000  $400,000  $450,000  $500,000  $600,000  $700,000  $750,000  $800,000  $900,000  $1,000,000  $1,250,000  $1,500,000  $1,750,000  $2,000,000  $2,500,000  $3,000,000  $5,000,000
Premiums Paid:	Annual   Monthly
Best Time To Call:	Select morning 8:00am to 12:00 midday 12:00 - 2:00 afternoon 2:00 - 6:00  evening 6:00 - 10:00

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