Quick Quote Life Insurance from: State Farm Insurance
827 N. Last Chance Gulch, Helena - 406-442-9900
Today's Date:	MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember  Day01020304050607080910 1112131415161718192021 22232425262728293031  Year060708
Your First Name:
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State of Residence:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Gender:	MaleFemale
Date of Birth:	JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991
Height:	4 5 6   feet   0 1 2 3 4 5 6 7 8 9 10 11 inches
Weight:
Tobacco or Nicotine Use:	Never None in last 5 years None in last 4 years None in last 3 years None in last 2 years None in last 1 year Current User
Preferred Insurance:	Term Life Cash Value Whole Life Universal Life Variable Life Don't Know
Coverage Amount:	50,000 75,000 100,000 125,000 150,000 175,000 200,000 225,000 250,000 275,000 300,000 325,000 350,000 375,000 400,000 425,000 450,000 475,000 500,000 600,000 700,000 750,000 800,000 900,000 1,000,000 1,250,000 1,500,000 1,750,000 2,000,000 2,250,000 2,500,000 2,750,000 3,000,000 3,250,000 3,500,000 3,750,000 4,000,000 4,250,000 4,500,000 4,750,000 5,000,000 6,000,000 7,000,000 8,000,000 9,000,000 10,000,000
Length of Coverage:	5 10 15 20 25 30 years
Premium Payment Mode:	Annual Semi-Annual Quarterly Monthly
What is your current blood pressure level?	Don't Know Below 135/80 Below 140/85 Below 145/90 Above 145/90
What is your current cholesterol level?	Don't Know Below 220 Below 240 Below 260 Above 260
Are you currently being treated for hypertension or high cholesterol?	No Yes
Have any of your parents or siblings been diagnosed with cancer or cardiovascular disease prior to age 60?	Don't Know No Yes
Have any of your parents or siblings died from cancer or cardiovascular disease prior to age 60?	Don't Know No Yes
Do you routinely travel outside the United States?	No Yes
Do you participate in hazardous activities?	No Yes
Do you participate in private aviation?	No Yes
Have you been diagnosed with or received treatment for any of the following conditions? Cardiovascular disease Cancer Depression Sleep Apnea Asthma Diabetes Kidney Disease Liver Disease Mental or Nervous Disorder Alcohol/Drug Abuse or Dependency Crohn's disease	No Yes