Applicant Information: ID# 998079
Name: XXXX XXXXXXXX Gender: XXXXXXXX Birth date: 12/14/48 
Address: XXXXX XXXXXXXXXX XXXX   City: Farmington   State: New Mexico    Zip: XXXXX
Work Phone: XXX-XXX-XXXX Home Phone: XXX-XXX-XXXX Best Time To Call: 8-20 a.m.
E-mail Address: 
Quote Information:
Are you requesting for yourself? Yes
Insurance Request Information: Health Information:
Amount of insurance wanted: $1,000,000 - $2,000,000

Do you use Tobacco: No

Type of insurance wanted: Whole Life

What type of tobacco products: N/A

Primary purpose(s): Income to family after death

Height: 5' 7"

What term would you like: 99

Weight: 178

Amount of Insurance now in force: $750,000.00

Health Problems: None

Premium you are paying per year: $7500.00

Medications: None

When is the last time you applied: 5+ years ago

Names/doses: N/A

To which companies: AXA Advisors

Family member - Heart Disease/Cancer: None

What Was The Outcome: Accepted

Describe: N/A

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