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Ease photocopy your insurance card (front and back) or a copy of your insurance form and attach to application. Have you ever had any of the following? Yes Skin conditions Eye trouble Ear trouble Head injury Recurrent headache Epilepsy Fainting spells Mental or Nervous disorders Weakness Paralysis Insomnia Shortness of breath Hay fever Venereal disease High blood pressure Low blood pressure Rheumatism / Arthritis Back Problems Tumor / Cancer No Yes No Dislocation of joints Broken bones Sto.

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