Best phone contact
*Your date of birth
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*Are you a tobacco user
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Additional Health Questions: (will get a more accurate rate, but not needed for quote)
Do you have a history of cancer, heart disease, diabetes or are you permanently disabled?
Weight in pounds
Have you ever been treated for or taken medication for high blood pressure?
Have you ever been treated for or taken medication for high cholesterol?
Have you ever been convicted of drunken driving (DUI/DWI)?
Have you ever been convicted of reckless driving?
Has your license ever been revoked or suspended?
Have you ever had more than one accident?
Please indicate the TOTAL number of moving violations/tickets (i.e. not parking tickets) that you have received in the last 5 years
Please indicate the total number of family members(parents or siblings) who have died from cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70:
Not including those who died, please indicate the total number of family members(parents or siblings) ho have contracted cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney isease before the age of 70: