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Personal Information

Gender * Male Female Non-binary

Health & Lifestyle

Tobacco / Nicotine Use? * No Yes — Currently Former User (quit 1+ year ago) General Health * Excellent Good Average Below Average

Any major health conditions? No Yes

Coverage Details

Coverage Amount $25,000 $50,000 $100,000 $250,000 $500,000 $1,000,000+ Not Sure Coverage Duration 10 Years 15 Years 20 Years 30 Years Lifetime (Whole Life) Not Sure

Number of Dependents 0 1–2 3–4 5+ Monthly Budget $25 – $50/mo $50 – $100/mo $100 – $200/mo $200+/mo Not Sure

Contact Preference

Preferred Contact Method Phone Call Email Text Message Best Time to Reach You Morning (8am–12pm) Afternoon (12pm–5pm) Evening (5pm–8pm)

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