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Step
1
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Gender
Male
Female
They
Marital Status
Married
Single
Civil Partnership
Common-Law
Cohabiting
Divorced
Separated
Widowed
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What type of Insurance do you want?
*
Life Insurance
Health Insurance
Do you already have an Insurance?
Yes
No
Next
Cover Amount for Life Insurance
*
Policy Duration for Life Insurance
*
In the last 5 years have you had any of these?
*
Depression
Anxiety
Stress
Any Other Mental Health Issue
None of these
Have you ever had any of these?
*
Eating Disorder
Bipolar Disorder
Manic Depression
Schizophrenia
Psychosis
None of these
In the last 5 years have you had any of these?
*
Raised blood pressure, cholesterol, or chest pain
Diabetes or raised blood sugar
Anemia, blood clot, or anything else affecting your blood
A growth, lump, or cyst
Asthma, sleep apnoea, or anything else affecting your lungs or breathing
Kidney stones, urinary infection or anything else affecting your kidneys, prostate, bladder or urine
Back pain, sciatica, whiplash or anything else affecting your back or neck
Impaired, blurred or double vision, optic neuritis or anything else affecting your eyes
None of these
Cover Amount for Health Insurance
*
Policy Duration for Health Insurance
*
What type of coverage are you interested in?
Individual Health Plan
Family Health Plan
Short-Term Health Plan
Dental & Vision Coverage
Other (Please specify)
Specify Here
*
What is your monthly budget for health insurance?
Under $100
$100 - $200
$200 - $500
$500+
Have you experienced any of these conditions?
Back pain, sciatica, or any spinal-related issues
Anemia, blood clot, or blood-related disorders
Migraines, blurred vision, or optic neuritis
Digestive disorders (e.g., ulcers, reflux, IBS)
Impaired vision or hearing
Joint pain, arthritis, or bone-related issues
None of these
Submit
DEHART INSURANCE GROUP
(304) 752-1080
leroy@dehartinsurance.com
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