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Do you plan to replace or lapse any existing life insurance policy (does not include employer provided policies)?
Do you currently use prescription medications?
Do you have any family history of cardiovascular disease or cancer in your parents or siblings, prior to age 61?
Have you ever had any life insurance rated, restricted, cancelled or declined?
Have you had any speeding tickets, moving violations, DUIs, license suspensions or revocations in the past 5 years? If yes please provide details below.
Have you used any form of tobacco or nicotine in the last 5 years? (including Nicotine patches)
If yes, what was the last date of use?
Have you ever had or been treated for any of the following medical conditions:
Alcohol or Drugs
Ulcerative Colitis or Iletis
Kidney or Liver Disease
If Other, which medical condition?