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Insurance Pre-Assessment Questionnaire

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

Secured
1

Your name?

2

What is your Date of Birth?

Select a date
3

What is your height in CMS?

Use digits only
4

What is your weight in KGS?

Use digits only
5

Are you a smoker?

Select one or more answers
6

If yes, please complete the following

Write in the blank fields below