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Critical Illness Insurance Quote Form
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11
Questions
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1
How much Critical illness insurance do you want a quote for?
*
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2
What is your Birthday?
*
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3
What is your Gender?
*
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Male
Female
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4
Have you smoked within the last 12 months
*
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YES
NO
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5
How Would You Rate Your Health?
POOR
Average
Great
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6
What province do you reside in?
*
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Ontario
Quebec
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7
E-mail
*
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8
Phone Number
*
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Area Code
Phone Number
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9
What is your Name?
*
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First Name
Last Name
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10
What is the best time to reach you?
Morning
Afternoon
Evening
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11
Please verify that you are human
*
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