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Covered Individual
First Name of Insured*
Last Name of Insured*
Email*
Street Address
City
State
Zip code
Covered Individual
Is this individual Active Military or Veteran?*
Firearm Ownership*
Footspeed*
Mechanical Aptitude*
Intelligence*
Outdoorsiness*
Eyesight*
Body Stank*
Designated Beneficiary
First Name of Beneficiary*
Last Name of Beneficiary*
Relationship to Insured Party*
Coverage Amount
Coverage Amount*
My agency is Axcess Insurance Services*