Agent's Phone Number: * Agent's Email: * State of Issue/Delivery: * Alabama Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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? **Our underwriters may need additional information in order to provide quote. Have you ever been treated for, or diagnosed with: (If “yes,” please provide details under each question.) High blood pressure, heart attack, chest pain, heart murmur, irregular heartbeat, stroke, or any other disease or disorder of the heart or blood vessels? Cancer or a tumor, cyst or growth? Asthma, bronchitis, emphysema, sleep apnea, tuberculosis or any other disease or disorder of the lungs or respiratory system? Seizure, paralysis, headaches, multiple sclerosis or any other disease or disorder of the brain or nervous system? Chronic fatigue, stress, depression, anxiety or any emotional or psychological disorder? Hepatitis, colitis, ulcer, cirrhosis, irritable bowel or any other disease or disorder of the liver, gall bladder, pancreas, or digestive tract? Diabetes, borderline diabetes, sugar in the urine, thyroid disorder, or any other disease or disorder of the glandular system? Kidney stones, nephritis, any blood or protein in the urine, sexually transmitted disease, prostate disorder, breast disorder or any other disease or disorder of the urinary or reproductive system? Any disease or disorder of the bones, joints, or muscles? Have your parents or siblings died as a result of cancer, stroke, or heart disease prior to age 60?
Select all that apply
Are you currently or have you taken any medications (prescription or otherwise) within the last two years? Have you had any surgeries in the last 6 months or are there plans for surgery in the near future? Have you engaged in any of the following activities: aviation, scuba/skin diving, organized motor vehicle racing (i.e. snowmobile or motorboat), skydiving, hang gliding, mountain climbing, or rodeo? Have you traveled outside the U.S. or Canada? Have you been in an auto accident, convicted of a driving while intoxicated, or have more than two moving violations? Have you been on parole or probation or convicted of a felony or misdemeanor? Have you regularly used, or are you currently using any controlled substance, excluding marijuana? Have you ever been medically advised to limit or discontinue the use of alcohol or drugs, or sought or received treatment? Do you exercise regularly? Please provide additional details about the proposed insured’s medical history: