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Final Expense Whole Life




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Personal Information
First Name
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Last Name
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State
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Primary Phone Number
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E-Mail Address
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Gender
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Date of Birth
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Tobacco Used?
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Do you currently receive kidney dialysis or require oxygen use or have you received or been told that you need an organ transplant or have you been diagnosed as having a terminal illness?
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Do you require assistance to feed, bathe, dress or take your own medication or are you currently confined to a hospital, nursing home, mental facility, hospice, or require home health nursing care?
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Have you ever tested positive for the AIDS virus or been diagnosed or treated, or recommended for treatment for AIDS,ARC or any other immune disorder?
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In the past twelve (12) months:
Other than for temporary or minor conditions, have you been hospitalized two or more times?
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Other than preventive, maintenance or risk lowering medications prescribed, have you been treated for or diagnosed with any cancer, heart attack, stroke, or had heart surgery?
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Have you used any illegal drugs, been treated for or advised to have treatment for drug abuse?
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In the past 2 years:
Have you been diagnosed or treated for, or are you currently under treatent for:
Alzheimer's Disease or Dementia?
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Any form of Cancer (other than Basal Cell skin cancer) or Brain Tumor?
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Other than preventive, maintenance or risk lowering medications prescribed, have you been diagnosed or treated for Heart or Circulatory Disorder (except controlled hypertension) or Stroke?
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Had surgery for any Heart Disorder (including angioplasty) or Circulatory Disorder (except varicose veins)?
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Sickle Cell Anemia or Kidney Disease (including dialysis) or Liver Disease (including hepatitis B & C)?
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Lung Disease (except controlled, mild asthma not requiring any hospitalization in the past 2 years)?
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ALS (Lou Gehrig's Disease) or Neurological disorders (except for controlled seizure disorder with no seizures in the past 2 years)?
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Have you been advised by a medical professional to have any tests, surgery, treatment, or further medical evaluation that have not been performed or do you have any medical tests results pending?
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Have you excessively used, been treated for or been advised to have treatment for alcohol or drug abuse?
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In the past 10 years
Have you been convicted of a felony or currently have pending charges for a felony; or currently on parole from a felony conviction?
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In the past 2 years:
Have you been diagnosed or treated for, or are you currently under treatment for:
Schizophrenia or Bipolar Disorder
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Diabetes requiring insulin treatment?
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SLE(Systemic Lupus Erythematosus)?
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Have you been convicted of operating a vehicle while intoxicated, or had you driver's license suspended or revoked?
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Have you been declined or postponed for Life Insurance?
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If under age 65, are you currently disabled, or been disabled in the last six months or at any time during the last six months received any disability compensation?
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Have you been mentally or physically unable to complete 30 hours per week of active employment?
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Do you now participate in, or do you have plans to participate in any hazardous sport or aviation?
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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