First Name:  * Last Name:  * Email Address:  * Address: City: State: Zip Code: DOB:  * Sex: MaleFemale Height:  * Weight:  * Are you a US Citizen?: YesNo Pay Out Amount: $25000$35000 $50000 In the last 2 yrs have you had?: Heart or circulatory disorderUnexplained weight lossFibrocystic breast diseaseUnexplained growths or tumorsUnexplained FatigueUnexplained DizzinessAbnormal PAP SmearNone of these conditions If more than 1 condition, list here: In the past 2yrs have you been diagnosed with?: Stroke/Transient Ischemic AttachHeart AttackAlcoholismDrug AbuseCancer (other than skin cancer)MelanomaRecurrent Human Papillion Virus (HPV)Sexually transmitted DiseaseAIDS/ARC or AIDS related conditionDiabetesHepatitis B or CChronic Lung DiseaseCirrhosis Skin Cancer (2 or more occurrences)Ulcerative ColitisCrohn's DiseaseAlzheimer's or Senile DementiaSystolic Blood Pressure 150 or greater - last 6mthsDiastolic Blood Pressure 95 or greater - last 6mthsNone of these conditions If more than 1 condition, list here: Have you been postponed or declined for a Critical Illness plan? YesNo Have you had a parent diagnosed with any of the above conditions? YesNoI do not know If yes: please state mother or father / what condition and at what age: Do you plan to travel outside the United States/Canada within the next year for more than 2 months?: YesNo Have you used tobacco or nicotine in the past 12 mts?: YesNo Questions or Comments: Security code:   * Do not enter anything in this field:

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