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Marital Status?

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Marital Status?

A

Single

B

Married

C

Widow

D

Divorced

E

Separated

F

Other

Nationality?

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Existing life insurance?

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Existing life insurance?

A

Yes

B

No

C

Other

Existing retirement pension?

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Existing retirement pension?

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Yes

B

No

C

Other

Exisiting disability insurance?

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Exisiting disability insurance?

A

Yes

B

No

C

Other

Existing health insurance

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Existing health insurance

A

Yes

B

No

C

Other