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Next < Back Some more basic information is needed We'll use this info to further personalize your rate Do You Own The House Select.. YES NO Number Of Years You Are Staying There Number Of Months You Are Staying There Marital Status Select... Single Married Separated Divorced Domestic Partner Widowed What Is Your Highest Qualification Select... Less than High School Some or No High School High School Diploma Some College Associate Degree Bachelors Degree Masters Degree Doctorate Degree Other Are You Employed Select... YES NO What Is Your Occupation Select... Accounts Pay/Rec. 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YES NO Next < Back Some more basic information is needed We'll use this info to further personalize your rate What Is Your Height 200cm What Is Your Weight 200pow Any Major Medical Conditions You Have Select... Ongoing Medical Treatment Currently Hospitalized? HIV / AIDS Alcohol Drug Abuse Alzheimers Disease Cancer Cholesterol Depression Diabetes Heart Disease High Blood Pressure Kidney Disease Liver Disease Mental Illness Pulmonary Disease Stroke Ulcer Vascular Disease Pregnancy Asthma Hepatitus B Skin Related Disease Transientes Chemic Attack Arthritis Eye Or Sight Disorder Lupus Seizure Neurosis Any Other Have You ever being charged with a serious offense like DUIs or DWI? Select... YES NO What type of health Coverage Do You Need? Select... Individual Plan Family Plan Medicare Supplement Have You Previously Denied For Coverage? Select... YES NO Number Of People In Your Household What type of health Coverage Do You Have? Select... Individual Plan Family Plan Medicare Supplement Current Insurance Company Select... Company Not Listed 21st Century Insurance AAA Insurance Co. 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