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Something about yourself, you are a

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Who all would you like to get insured?

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How old is each member? Tell us the age

Self

Age 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years 27 Years 28 Years 29 Years 30 Years 31 Years 32 Years 33 Years 34 Years 35 Years 36 Years 37 Years 38 Years 39 Years 40 Years 41 Years 42 Years 43 Years 44 Years 45 Years 46 Years 47 Years 48 Years 49 Years 50 Years 51 Years 52 Years 53 Years 54 Years 55 Years 56 Years 57 Years 58 Years 59 Years 60 Years 61 Years 62 Years 63 Years 64 Years 65 Years 66 Years 67 Years 68 Years 69 Years 70 Years 71 Years 72 Years 73 Years 74 Years 75 Years 76 Years 77 Years 78 Years 79 Years 80 Years 81 Years 82 Years 83 Years 84 Years 85 Years 86 Years 87 Years 88 Years 89 Years 90 Years 91 Years 92 Years 93 Years 94 Years 95 Years 96 Years 97 Years 98 Years 99 Years 100 Years

Spouse

Age 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years 27 Years 28 Years 29 Years 30 Years 31 Years 32 Years 33 Years 34 Years 35 Years 36 Years 37 Years 38 Years 39 Years 40 Years 41 Years 42 Years 43 Years 44 Years 45 Years 46 Years 47 Years 48 Years 49 Years 50 Years 51 Years 52 Years 53 Years 54 Years 55 Years 56 Years 57 Years 58 Years 59 Years 60 Years 61 Years 62 Years 63 Years 64 Years 65 Years 66 Years 67 Years 68 Years 69 Years 70 Years 71 Years 72 Years 73 Years 74 Years 75 Years 76 Years 77 Years 78 Years 79 Years 80 Years 81 Years 82 Years 83 Years 84 Years 85 Years 86 Years 87 Years 88 Years 89 Years 90 Years 91 Years 92 Years 93 Years 94 Years 95 Years 96 Years 97 Years 98 Years 99 Years 100 Years

Son 1

- +

Age 17-90 Days 3-12 Months 1 Years 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years

Son 2

Age 17-90 Days 3-12 Months 1 Years 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years

Son 3

Age 17-90 Days 3-12 Months 1 Years 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years

Son 4

Age 17-90 Days 3-12 Months 1 Years 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years

Daughter 1

- +

Age 17-90 Days 3-12 Months 1 Years 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years

Daughter 2

Age 17-90 Days 3-12 Months 1 Years 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years

Daughter 3

Age 17-90 Days 3-12 Months 1 Years 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years

Daughter 4

Age 17-90 Days 3-12 Months 1 Years 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years

Father

Age 35 Years 36 Years 37 Years 38 Years 39 Years 40 Years 41 Years 42 Years 43 Years 44 Years 45 Years 46 Years 47 Years 48 Years 49 Years 50 Years 51 Years 52 Years 53 Years 54 Years 55 Years 56 Years 57 Years 58 Years 59 Years 60 Years 61 Years 62 Years 63 Years 64 Years 65 Years 66 Years 67 Years 68 Years 69 Years 70 Years 71 Years 72 Years 73 Years 74 Years 75 Years 76 Years 77 Years 78 Years 79 Years 80 Years 81 Years 82 Years 83 Years 84 Years 85 Years 86 Years 87 Years 88 Years 89 Years 90 Years 91 Years 92 Years 93 Years 94 Years 95 Years 96 Years 97 Years 98 Years 99 Years 100 Years

Mother

Age 35 Years 36 Years 37 Years 38 Years 39 Years 40 Years 41 Years 42 Years 43 Years 44 Years 45 Years 46 Years 47 Years 48 Years 49 Years 50 Years 51 Years 52 Years 53 Years 54 Years 55 Years 56 Years 57 Years 58 Years 59 Years 60 Years 61 Years 62 Years 63 Years 64 Years 65 Years 66 Years 67 Years 68 Years 69 Years 70 Years 71 Years 72 Years 73 Years 74 Years 75 Years 76 Years 77 Years 78 Years 79 Years 80 Years 81 Years 82 Years 83 Years 84 Years 85 Years 86 Years 87 Years 88 Years 89 Years 90 Years 91 Years 92 Years 93 Years 94 Years 95 Years 96 Years 97 Years 98 Years 99 Years 100 Years

Grand Father

Age 54 Years 55 Years 56 Years 57 Years 58 Years 59 Years 60 Years 61 Years 62 Years 63 Years 64 Years 65 Years 66 Years 67 Years 68 Years 69 Years 70 Years 71 Years 72 Years 73 Years 74 Years 75 Years 76 Years 77 Years 78 Years 79 Years 80 Years 81 Years 82 Years 83 Years 84 Years 85 Years 86 Years 87 Years 88 Years 89 Years 90 Years 91 Years 92 Years 93 Years 94 Years 95 Years 96 Years 97 Years 98 Years 99 Years 100 Years

Grand Mother

Age 54 Years 55 Years 56 Years 57 Years 58 Years 59 Years 60 Years 61 Years 62 Years 63 Years 64 Years 65 Years 66 Years 67 Years 68 Years 69 Years 70 Years 71 Years 72 Years 73 Years 74 Years 75 Years 76 Years 77 Years 78 Years 79 Years 80 Years 81 Years 82 Years 83 Years 84 Years 85 Years 86 Years 87 Years 88 Years 89 Years 90 Years 91 Years 92 Years 93 Years 94 Years 95 Years 96 Years 97 Years 98 Years 99 Years 100 Years

Father-in-law

Age 35 Years 36 Years 37 Years 38 Years 39 Years 40 Years 41 Years 42 Years 43 Years 44 Years 45 Years 46 Years 47 Years 48 Years 49 Years 50 Years 51 Years 52 Years 53 Years 54 Years 55 Years 56 Years 57 Years 58 Years 59 Years 60 Years 61 Years 62 Years 63 Years 64 Years 65 Years 66 Years 67 Years 68 Years 69 Years 70 Years 71 Years 72 Years 73 Years 74 Years 75 Years 76 Years 77 Years 78 Years 79 Years 80 Years 81 Years 82 Years 83 Years 84 Years 85 Years 86 Years 87 Years 88 Years 89 Years 90 Years 91 Years 92 Years 93 Years 94 Years 95 Years 96 Years 97 Years 98 Years 99 Years 100 Years

Mother-in-law

Age 35 Years 36 Years 37 Years 38 Years 39 Years 40 Years 41 Years 42 Years 43 Years 44 Years 45 Years 46 Years 47 Years 48 Years 49 Years 50 Years 51 Years 52 Years 53 Years 54 Years 55 Years 56 Years 57 Years 58 Years 59 Years 60 Years 61 Years 62 Years 63 Years 64 Years 65 Years 66 Years 67 Years 68 Years 69 Years 70 Years 71 Years 72 Years 73 Years 74 Years 75 Years 76 Years 77 Years 78 Years 79 Years 80 Years 81 Years 82 Years 83 Years 84 Years 85 Years 86 Years 87 Years 88 Years 89 Years 90 Years 91 Years 92 Years 93 Years 94 Years 95 Years 96 Years 97 Years 98 Years 99 Years 100 Years

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Do you have an existing illness or medical history?

This helps us find plans that cover your condition and avoid claim rejection

• Existing illness Blood pressure, Diabetes, Heart conditions, Asthma, Thyroid, Cancer etc.
• Surgical procedure Appendix, Gall bladder, C-section etc.
• Covid 19 Tested positive for Covid-19
• None of the above

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