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    reinstatement yes


    reinstatement no


    upgrade yes


    upgrade no


    family member yes


    family member no


    guaranteed conversion yes


    guaranteed conversion no




    applicant male


    applicant famale




    spouse male


    spouse female
















    dependent 1 male


    dependent 1 female


    dependent 2 male


    dependent 2 female


    dependent 3 male


    dependent 3 female


    dependent 4 male


    dependent 4 female


    dependent 5 male


    dependent 5 female


    dependent 6 male


    dependent 6 female













    actively at work yes


    actively at work no


    insurance replace yes


    insurance replace no


    insurance replace spouse yes


    insurance replace spouse no


    insurance replace dependents yes


    insurance replace dependents no




    own other insurance yes


    own other insurance no


    own other insurance spouse yes


    own other insurance spouse no


    own other insurance dependent yes


    own other insurance dependent no



    Section 4 Q 2 Yes


    Section 4 Q 2 No


    Section 4 Q 3 Yes


    Section 4 Q 3 No


    Section 4 Q 4 Yes


    Section 4 Q 4 No


    Section 4 Q 5 Yes


    Section 4 Q 5 No


    Section 4 Q 6 Yes


    Section 4 Q 6 No


    Section 4 Q 7 Yes


    Section 4 Q 7 No


    Section 5 Individual


    Section 5 Individual Plus Children


    Section 5 Individual Plus Spouse


    Section 5 Family


    Section 5 Level 1


    Section 5 Level 2


    Section 5 Level 3


    Section 5 Level 4


    Sec 5 Rider Off the Job


    Section 5 Coverage Amt $500


    Section 5 Coverage Amt $1000


    Section 5 Coverage Amt $1500


    Section 5 Coverage Amt $2000


    Payroll Deduction


    Payroll Frequency 24