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First Name
M.I.
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
Country
E-mail Address
Phone
Gender
Date of Birth
Have you ever used any form of tobacco?
Yes
No
Have you ever been declined for insurance?
Yes
No
Are you currently taking any prescription medications?
Yes
No
Have you ever been treated for high blood pressure or cholesterol?
Yes
No
Has any member of your family been treated for coronary artery disease or cancer?
Yes
No
In the past 3 years have you had 3+ moving violations or had your driver's license suspended or revoked or been convicted of a DUI?
Yes
No
Have you ever been told by a physician, psychiatrist, psychologist or other medical practitioner you had, or been treated for: diabetes, fainting, seizure, alcoholism, depression, cardiovascular, respiratory, digestive, liver, kidney, or blood disease/disorder?
Yes
No
Explanations of all "yes" answers:
Type of Coverage
Are you a current or previous customer of Yes Insurance Agency or Joel Ciotta?
Yes
No
How did you hear of Yes Insurance?