from Special Plans of Tennessee
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Something About Yourself
We'll use it to provide you with the most cost effective life insurance plan possible.

Name: Optional Please type in John Doe
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Full Mailing Address: Optional

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E-mail: Fax: Phone: or Mail
Best Time to Contact You:

What is your date of birth?
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What is your sex?
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Do you smoke cigarettes?
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Do you use any other tobacco products?
Pipe, Cigar, Chew, Dip - Enter all used below:

What is your height?
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What is your weight?
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What prescription drugs do you now take?
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What dollar amount of life insurance do you need?
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What Type of Life Insurance Do You Want Quoted?

Term Insurance: Enter time desired below
10yr - 15yr - 20yr - 25yr - 30yr
Permanent Insurance: Whole Life /Universal Life
Enter Kind and Y or N below:

We Sincerely Appreciate Your Feedback

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Also please let us know about any questions, requests, or comments you may have regarding our services.

Thank you.

INTERNATIONAL Medical Insurance

 © 2000, Special Plans of Tennessee, P.O. Box 30308, Knoxville, Tn 37930-0308
• Phone 865-769-3772 / Toll Free 888-225-8556 / Fax 865-769-3753 •