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Product		Please select IRAs Guaranteed Term Life Universal Life 2nd-to-die (Survivorship LTC (nursing home insurance Disability Annuities College Funding Programs
If Guaranteed Term Life selected, how long?		(10 to 35 years)
Insurance Amount		Please select above $2,500,000 $2,500,000$2,000,000$1,500,000$1,000,000$950,000$900,000$850,000$800,000$750,000$700,000$650,000$600,000$550,000$500,000$450,000$400,000$350,000$300,000 $250,000$200,000$150,000$100,000
Do you currently own an Annuity?		Please select Yes No
Are you interested in Annuity information?		Please select Yes No
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Tobacco use		Please SelectNever used nicotineQuit less than 1 yr agoQuit 1-3 yrs agoSmoke cigarettesUse cigars, patch
Health Status		Please SelectExcellentGoodFairPoor
Health conditions		Please select Yes No
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