Birth Date: Day Month --------------------------- JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST CEPTEMBER OCTOBER NOVEMBER DECEMBER Year ------------------ 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Gender              --------------------- Male Female

Marital Status:  Single Married:     No of childern Other

Height (cm)        Weight (kg)  

Tobacco Use?  No   Yes:  Number of Cigarettes per day

Coverage Amount     Coverage Length       ------------------------ 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years

   Profession          Average Annual Income ------------------------ 1-5000 5001-10000 10001-20000 20001-50000 50001-100000 Above 100000

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