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Age

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Male Female

Tobacco use (Ever?)

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Select the Critical Illnesses that need to be covered by the quoted products:

Heart Attack
Cancer
Stroke
Acquired Brain Injury
Alzheimer's Disease
Aortic Surgery
Aplastic Anaemia
Autism
Bacterial Meningitis
Benign Brain Tumour
Blindness
Cerebral Palsy
Coma

Congenital Heart Disease
Coronary Angioplasty
Coronary Artery Surgery
Cystic Fibrosis
Deafness
Dismemberment
Heart Surgery
Heart Valve Replacement
Kidney (Renal) Failure
Loss of Independence
Loss of Limbs
Loss of Speech

Major/Vital Organ Failure/Transplant
Motor Neuron /Lou Gehrig's Disease
Multiple Sclerosis
Muscular Dystrophy
Occupational HIV
Paralysis
Parkinson's Disease
Rett Syndrome
Severe Burns
Type 1 Diabetes Mellitus

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