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8. Have you ever used any form of tobacco or nicotine based products? (required)
YN

a. If yes, When did you last use tobacco or nicotine based products? Month & Year?

9. Do you or have you ever consumed any type of alcoholic beverage ? (required)
YN

a. If yes, Do you have a history of alcoholic abuse?
YN

b. If yes, Has there been any abuse in the last 10 years?
YN

10. Have you had any DUI's in the past 5 years? (required)
YN

a. If yes, Have you had any DUI's in the past 3 years?
YN

11. Do you have or have you ever used any type of illegal drugs? (required)
YN

a. If yes, Do you have a history of substance abuse?
YN

b. If yes, Has there been any abuse in the last 10 years?
YN

12. Have you had more than two moving violations in the past three years? (required)
YN

14. Has any parent or sibling had a history of cardiovascular disease or cancer before age 60? (required)
YN

a. If yes, Has either parent died as a result of cardiovascular disease or cancer before age 60?
YN

b. If yes, Has both parents died as a result of cardiovascular disease or cancer before age 60?
YN

15. Term Period?
10152030

17. Billing Frequency?
AnnualSemi-AnnualQuarterlyMonthly

18. Method of Payment?
EFTDirect Bill

19. Is this prospective policy to replace any existing insurance?
YN