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? Military Status
If your duties include Aviation, please also complete the DBS Aviation Questionnaire.
Present Rank: Present unit, assignment, and location: Military occupational specialty: Is the proposed insured involved in any hazardous activities (e.g. aviation, diving, parachuting bomb disposal, special service groups, etc.) Is the proposed insured receiving any supplemental or hazardous duty pay based on their duties? Is the proposed insured aware of or been told of any of the following? Does the proposed insured take any medications (prescription or otherwise) at this time? Please provide additional details about the proposed insured’s medical history: