Birthday	DOB (MM/DD/YYYY)   / /
Gender	Male Female
State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Amount of Insurance	$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 $275,000 $300,000
Payment Option	Annual Semi-Annual Monthly Quarterly
Height	4 5 6 7 ft. 0 1 2 3 4 5 6 7 8 9 10 11
Weight	lbs.
Does your client smoke or use tobacco?:	Yes No
Is your client residing in a hospital or long-term-care facility?	Yes No
Does your client have AIDS or HIV?	Yes No
Has your client been declared terminally ill, defined as having less than 24 months to live?	Yes No