LTC Insurance
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Any tobacco usage in the past 12 months? yes no
   
Any alcohol consumption in the past 12 months? yes no
   
Has you ever been denied 'Long Term Care' coverage? yes no
   
Is there any current health or long term care policy in force? yes no
   
Do you live in some form of residential retirement community? yes no
   
Are you receiving any ongoing medical treatments? yes no
   
Who do you reside with?
   
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