Buy Insurance Step 4

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First Name

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Last Name

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Date

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Age

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Gender

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Mobile Number

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Current Height (cm)(Required)

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Current Weight (kg)(Required)

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Occupation(Required)

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Monthly Income (PKR)(Required)

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Do you intake Tobacco or Nicotine in any form? Yes or no

Yes

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Do you intake Tobacco or Nicotine in any form?

0-5 times

5 to 10 times

10 to 20 times

Can't specify

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Consume Alcohol Yes or no

Yes