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Gender
Date of birth
Height
Weight
Smoker?
Applicant
M
F
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Ft
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7
In
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11
Spouse
--
M
F
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/
Ft
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Children
0
1
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6
Children
--
M
F
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Ft
0
1
2
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5
6
7
In
0
1
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6
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8
9
10
11
Children
--
M
F
/
/
Ft
0
1
2
3
4
5
6
7
In
0
1
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8
9
10
11
Children
--
M
F
/
/
Ft
0
1
2
3
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Children
--
M
F
/
/
Ft
0
1
2
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5
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7
In
0
1
2
3
4
5
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9
10
11
Children
--
M
F
/
/
Ft
0
1
2
3
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Children
--
M
F
/
/
Ft
0
1
2
3
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Currently Insured?
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No
Have conditions?
Yes
No
Please specify
Take medications?
Yes
No
Please specify
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