Agent's Phone Number: * Agent's Email: * State of Issue/Delivery: * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Send to Additional Email? Proposed Insured's Name: * What is the proposed insured's: *
Please select "age" if the date of birth is unknown.
Height: * Weight: * Ever a marijuana/THC user? * Ever a cigarette smoker? * Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) * Is this case being premium financed? * Face Amount: * Are there multiple policies/face amounts? Are you requesting any riders? Drug Use Are you now using or have you ever used any of the following, other than for treatment of a medical condition under proper medical supervision? (Please check all that apply.) * Amphetamines, i.e. “Ecstasy,” “Ice,” MDMA, “Speed,” “Uppers,” etc. Barbiturates, i.e. “Downers,” etc. Cannabis, i.e. “Hashish,” Marijuana, “Pot,” “Weed,” etc. Cocaine, i.e. “Coke,” “Crack,” “Snow,” etc. Hallucinogens, i.e. “Acid,” “Angel Dust,” “Haze,” LSD, “Microdots,” etc. Herbs, i.e. catnip, poppy, kava kava, Lobelia, etc. Opiates, i.e. Codeine, Heroin, Methadone, Morphine, Opium, “Smack,” etc. Sedatives, i.e. Diazepam, “Downers,” Nitrazepam ”Tranks,” etc. Solvents, i.e. Aerosols, glue, etc. Alcohol Other Have you ever sought medical treatment due to drug usage or detoxification? * Have you suffered from any impairments associated with drug usage? (i.e. hepatitis B, HIV infection, mental illness, etc.) * Have you had any legal trouble because of drug use? * Are you currently attending meetings of N.A. or similar recovery group? * Does the proposed insured take any medications (prescription or otherwise) at this time? Please provide additional details about the proposed insured’s medical history: