Your Amount of Life Insurance Coverage desired? $25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $250,000 $300,000 $350,000 $400,000 $500,000 $750,000 $1,000,000 $1,500,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 Over $5,000,000

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In the past 12 months have you smoked cigarettes, cigars, pipe or used tobacco or nicotine in any form including snuff, dip, chew, nicotine patch, gum or other substitutes?
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