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What is the name of the insurance company for "your (1st, 2nd, 3rd)" life/disability policy? [enter text] __________________
* Enter name of insurance company, not the insurance agent.
Briefly describe the policy. [enter text] ______________
Are the policy premiums paid -
Are any premiums paid through payroll deductions?
Since the first of the reference month, what was your or your household total expense for this insurance policy? [enter value] ______________
* Enter the actual amount the household paid. Do not include any expenses paid for the household by others
How much was paid this month? [enter value] ______________
* Enter 'C' for a combined expense
What other type of policy is the "life/disability insurance" combined with?
* Enter all that apply, separate with commas
Which property (ies) does this policy cover? [enter text] ______________
Do you or any members of your household have any or make payments for any other "long term care insurance" policy?
End of Section 13B Life Insurance
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Last Modified Date: April 12, 2011