The following questions are required for an accurate life quote.
Please see our
Privacy Statement
Gender:
Male
Female
Date of Birth:
Height:
Weight (pounds):
Occupation:
Smoker or Non Smoker:
Recently quit smoking:
Check all that apply:
smoke
cigars
smoke
a pipe
chew
tobacco
nicotine
gum
on
The Patch
Take prescription medication:
** You are not required to complete the
medical health questions below to receive your life insurance quotes. You
may contact us if you have any questions.
If yes, state the medication, dosage (if known) and the condition it is
treating
Has any of parent sibling had cardiovascular disease or cancer?
If yes, please explain including age of onset, diagnosis, and death (if
applicable)
Ever been treated for any of
the following? (Check all that apply)
AIDS / HIV
Alcohol or Drugs
Alzheimer's Disease
Asthma
Cancer
Pulmonary Disease
Cholesterol
Diabetes
Depression
Heart Disease
Hypertension
Kidney Disease
Liver Disease
Mental Illness
Stroke
Ulcers
Vascular Disease
Other
If you checked any of the above, please explain date of onset or beginning
of treatment, diagnosis, and current status.
Are you a private or student
pilot?
If yes, please explain type of rating, type of aircraft, total number of
hours of experience, and number of hours flown per year (IFR, VFR,
single-engine, multi-engine, etc.)*
Do you engage in scuba diving, sky diving, rock climbing, motorized
racing, or any other hazardous avocation or occupation?
If yes explain below:
US
Citizen/Perm Resident
Yes
No
Have you ever been declined or rated for
Life insurance?
