Form_1_Extreme_Insurance

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  • Select Date of Birth
  • What is your gender?
    Do you smoke or use any nicotine products?

    You are considered a smoker if in the past 12 months you have used any form of tobacco products (cigarettes, cigarillos, pipes, chewing tobacco, e-cigarettes, hookah, nicotine patch/gum), smoked more than one cigar per month and/or have used tobacco vape.

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