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Zip code

Sex

Male

Female

Date of birth

Tobacco use

Yes

No

Years of coverage

10

15

20

25

30

Coverage amount

$

USD

Current health

Excellent

No medical conditions

Good

E.g., controlled hypertension and high cholesterol.

Moderate

E.g., diabetes, sleep apnea, depression or anxiety.

High Risk

E.g., history of cancer, HIV or heart attack.

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