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ip
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Insured
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Name
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DOB
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Weight
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Smoker
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If children are to be insured
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Do you or any family member to be insured have any current or previous medical problems?
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If yes, please explain
Capps Insurance - Mt. Pleasant
1610 Shadywood Lane
Mt. Pleasant, TX 75455
(903)572-4366
(800)256-1905
Capps Insurance - Clarksville
312 W. Broadway
Clarksville, TX 75426
(903)427-5656
(800)941-3444
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