Quote Application – The Insurance Box

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Life Insurance Quote Application

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Monthly Premium

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Last Name

Phone Number

Are you canadian citizen?*

Where were you born?*

Personal health questionnaires

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 been told to do any diagnostic test that you haven’t done or you are currently awaiting surgery/outpatient surgery?

Family medical history

Had any in your immediate family (Mother, Father, Brother, Sister) been diagnosed with cardiovascular disease,(Heart attack or stroke) cancer, diabetes or kidney disease?

How Did You Hear About Us ?

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Life Insurance Quote Application

Company

Monthly Premium

Personal health questionnaires

Family medical history

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