Keith King
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Home
About
Insurance Types
Contact
Get An Insurance Quote
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Step
1
of 3
name
Gender
Male
Female
Other
Marital Status
Married
Single
Civil Partnership
Common-Law
Cohabiting
Divorced
Separated
Widowed
Next
What type of Insurance do you want?
*
Life Insurance
Health Insurance
Do you already have an Insurance
Yes
No
Next
Cover Amount for Life Insurance
Policy Duration for Life Insurance
In the last 5 years have you had any of these?
*
Depression
Anxiety
Stress
Any Other Mental Health Issue
None of these
Have you ever had any of these?
*
Eating Disorder
Bipolar Disorder
Manic Depression
Schizophrenia
Psychosis
None of these
In the last 5 years have you had any of these?
*
Raised blood pressure, cholesterol, or chest pain
Diabetes or raised blood sugar
Anemia, blood clot, or anything else affecting your blood
A growth, lump, or cyst
Asthma, sleep apnoea, or anything else affecting your lungs or breathing
Kidney stones, urinary infection or anything else affecting your kidneys, prostate, bladder or urine
Back pain, sciatica, whiplash or anything else affecting your back or neck
Impaired, blurred or double vision, optic neuritis or anything else affecting your eyes
None of these
Cover Amount for Health Insurance
*
Preferred Deductible Amount
*
Type of Coverage Needed
*
Individual
Family
Group/Employer Provided
Have you been diagnosed with or treated for any of the following?
*
High blood pressure or hypertension
High cholesterol
Diabetes (Type 1 or Type 2)
Asthma, COPD, or other respiratory conditions
Heart disease or chest pain
Cancer or tumor
Kidney or liver disease
Any form of hepatitis
Mental health disorders (e.g., depression, anxiety)
None of these
Do you use tobacco products?
Yes
No
Do you consume alcohol?
Yes
No
Do any of your immediate family members have a history of the following conditions?
*
Heart Disease
Stroke
Diabetes
Cancer
Genetic Disorders
None of these
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