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Health Insurance

Please call or send me more information about:
 Individual Health
 Individual Dental
 Short Term Major Medical Health Plan
 Low Cost Hospital/Surgical Plan
 Medical Savings Accounts
 Equity Index or Fixed % Annuities
 Life Insurance
 Disability Insurance
 Long Term Care Insurance
 Medicare Supplements & Insurance
 Travel Insurance
 Tax deferred Savings Accounts
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Health history is always needed (we do not resell information to anyone for any purpose)
Do you have health conditions?  yes no ------- Please Detail yes answer below
Diagnosis? Chronic? Date of onset: Treatment or Surgery required? Is this covered currently?
Prescription medications?  yes no Explain: Yes,..... Rx name (mgs?) (x per day)
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