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					Daily benefit desired?*   $70 $80 $90 $100 $110 $120 $130 $140 $150 $160 $170 $180 $190 $200 $210 $220 $230 $240 $250 $260 $270 $280 $290 $300 Candidates birthday* Choose Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Choose 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Choose 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 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 Who is the candidate?* Choose Self Parent Brother/Sister In-Law Other Tobacco use?* No  Yes If so, how much? Choose Not sure $0 - $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 $11,000 $12,000 $13,000 $14,000 $15,000 $16,000 $17,000 $18,000 $19,000 $20,000 $21,000 $22,000 $23,000 $24,000 $25,000 $26,000 $27,000 $28,000 $29,000 $30,000 $31,000 $32,000 $33,000 $34,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000 $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 Other amount Receive payments when Choose Immediately 5 Years 10 Years 15 Years 20 Years 25 Years 25+Years  Candidates state*    Candidates zip code*     Inquiring person's info:   Name* Address* City* State* Zip code*     Email* {Check for email accuracy} Home phone* --  Please supply a valid phone. Work phone --  Ext Cell phone --     Best contact method* Choose Phone Email Phone & Email Best contact time Choose ASAP Anytime Morning Afternoon Evening 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12 Noon 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm 8:00 pm 9:00 pm Comments