Gender MaleFemale
Smoker YesNo
Date of Birth
Marital Status SingleMarriedDivorcedSeparatedWidowed
Coverage Less than $ 25,000$ 25,000$ 50,000$ 75,000$ 100,000$ 125,000$ 150,000$ 175,000$ 200,000$ 225,000$ 250,000$ 275,000$ 300,000$ 325,000$ 350,000$ 375,000$ 400,000$ 425,000$ 450,000$ 475,000$ 500,000More than $ 500,000
State CAFLGAILLAMIMSNVNCSCTX
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