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Name
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Email
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Phone Number
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Who is the insurance for?
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Select one option
Mother
Father
Both Parents
Age of Parent(s)
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Where does your parent live? (City/State in Nigeria)
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Does your parent have any health issues?
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Select one option
Yes
No
Unsure
If yes, please specify: (optional)
What type of coverage are you looking for?
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Basic coverage (doctor visits, minor treatment)
Comprehensive coverage (includes major treatments)
Emergency coverage
Not sure (need guidance)
What is your estimated budget per year?
What is most important to you?
Affordable cost
Access to good hospitals
Coverage for Major Illnesses
Easy Claims Process
Customer Support
Would you like help selecting the best plan?
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Select one option
Yes, I want full support
Maybe, I'd like to see options first
No, just send available plans
How soon are you looking to get insurance?
Select one option
Immediately
Within 1 month
Just exploring
Anything else we should know?
Sumbit
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