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Nsured used nicotine based products in the past 12 months? If yes, give name and address of existing insurer & policy number, if available: Policy Mailing: q Agent P-1146-R-VT q Owner 1 12/12 Proposed Insured: 6. Health Questions Part A Questions: If Proposed Insured answers YES to any question in Part A or does not meet the height and weight requirements, he/she is not eligible for coverage. If all.

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