Personal Information
First Name
Last Name
Address
City, Zip Code
Phone Number
Email Address
Height
3
4
5
6
7
8
feet
0
1
2
3
4
5
6
7
8
9
10
11
inches
Weight
Current Age
Gender
Female
Male
Are you a US citizen?
Yes
No
If yes, for how many months/years?
General Questions
Have you been involved in a hazardous occupation in the last
2 years?
Yes
No
Have you been involved in hazardous activities in the last
3 years?
Yes
No
Have you ever flown an aircraft as a pilot, co-pilot or crew
member of an aircraft in the last 3 years?
Yes
No
Are you an active member of the military or military reserve?
No
Yes, a commissioned
officer
Yes, a non-commissioned
officer
How many moving violations have you had in the last 3 years?
0
1
2
3
more than 3
Have you been convicted of a DUI/ DWI or reckless driving within
the last 10 years?
No
Within the last 5 years
Between 6 and 10 years
ago
Have you ever had more than 1 conviction for DUI/DWI or reckless
driving?
Yes
No
Have you lived outside of North America at any time during the
last 3 years?
Yes
No
Have you done any foreign travel (not Canada) in
the last two years or do you expect to do any foreign travel in
the next two years?
Yes
No
If yes, please list the countries:
Health Information
Check all those conditions for which you have been
treated or sought treatment:
What is your blood pressure?
I don't know
130 or lower
131-135
136-140
141-145
146-150
151-155
156-160
161-170
171-180
181-190
191-200
201-210
Higher than 210
I don't know
80 or lower
81-85
86-90
91-95
96-100
101-105
106-110
111-115
Higher than 115
Have you ever taken blood pressure medication?
Yes
No
What is your cholesterol level?
I don't know
160 or lower
161-170
171-180
181-190
191-200
201-210
211-220
221-230
231-240
241-250
251-260
261-270
271-280
281-290
291-300
301-310
311-320
321-330
331-340
Higher than 340
Have you ever taken cholesterol medication?
Yes
No
Have you used any tobacco products (cigarettes, cigars, dip,
snuff, chewing tobacco, pipe tobacco) or any nicotine substitutes
in the last 5 years?
No
Yes, in the past 12
months
Yes, 1-2 years ago
Yes, 2-3 years ago
Yes, 3-4 years ago
Yes, 4-5 years ago
To your knowledge, has anyone in your family (parents or siblings)
had cardiovascular disease before age 60?
Yes
No
Has cancer resulted in the death of an immediate family member
(parents or siblings) before the age of 60?
Yes
No
Coverage Options
Note: It is generally recommended that the main income earner have 8 to 10 times their annual income in life insurance.
Select the coverage amount for your term
$100,000
$200,000
$300,000
$400,000
$500,000
$750,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
Select the term for your policy:
10 years
15 years
20 years
30 years
ALL OF THE ABOVE
