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Do you have a history of alcohol or substance abuse?
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Do you have any DUIs in the past 5 years?
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Have you used any nicotine-based products in the past
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Has either parent or a sibling had a history of cardiovascular disease or cancer before age 60?
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Has either parent died as a result of cardiovascular disease or cancer before the age of 60?
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| The benefit amount I am interested in is... |
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| Height? |
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| I would like to be contacted |
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| The best way to contact me is... |
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