Please Confirm the Information Below
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date of Birth
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you a legal resident of the United States?
*
Yes
No
How much coverage are you looking for?
*
Please Select
$5,000
$7,500
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
Back
Next
1. Health
Have You Used Any Tobacco, Nicotine or Marijuana Products In the last 12 Months?
*
Yes
No
Tobacco type (Cigarette, Marijuana, Chew etc.?), Date of last use?, Frequency?
*
Height
*
Please Select
4'1
4'2
4'3
4'4
4'5
4'6
4'7
4'8
4'9
4'10
4'11
5'0
5'1
5'2
5'3
5'4
5'5
5'6
5'7
5'8
5'9
5'10
5'11
6'0
6'1
6'2
6'3
6'4
6'5
6'6
6'7
6'8
6'9
6'10
6'11
7'0
Weight
*
Have you ever been diagnosed with Diabetes?
*
Yes
No
At What Age Were You Diagnosed With Diabetes?
*
Have You Had Any Uncontrolled Diabetes in the Past 2 Years?
*
Yes
No
Have you had any complications with your diabetes such as: Neuropathy, Retinopathy, Diabetic Coma, Insulin Shock, or Amputation due to complications of Diabetes?
*
Yes
No
What Complications Have You Had?
*
Neuropathy
Retinopathy
Diabetic Coma
Insulin Shock
Amputation Due to Complications of Diabetes
Are You Taking Any Insulin?
*
Yes
No
At What Age Did You Start Taking Insulin? (Ballpark is Fine)
*
Which Insulin Are You Currently Taking?
*
Humalog
Novolog
Humulin
Novolin
Admelog
Lantus
Toujeo
Basaglar
Tresiba
Levemir
How Many Units of Insulin Are You Taking Per Day? (Average)
*
Have you ever been diagnosed or received treatment for Lung Disease? COPD, Emphysema or Asthma?
*
Yes
No
Which one? Are you receiving any treatment?
*
Do you require the use of any oxygen or inhalers?
*
Yes
No
Continuous Oxygen? Reason for use?
*
Have you ever been diagnosed with Cancer?
*
Yes
No
How many years have you been treatment-free?
*
Have you ever had any kidney insufficiency? Dialysis? Cirrhosis? Hepatitis?
*
Yes
No
Years since diagnosis? Still have it or resolved?
*
Have you ever had a Heart Attack, Bypass Surgery, Stent Surgery, Angina, Pacemaker, Defibrillator, Stroke, Seizure, Aneurism?
*
Yes
No
Which one? Years since last one?
*
Congestive Heart Failure?
*
Yes
No
Date of diagnosis? Any Nitroglycerin tabs used or prescribed?
*
Lupus? Multiple Sclerosis? Parkinson’s? Lou Gehrig’s?
*
Yes
No
Which condition?
*
Have you ever been diagnosed or received treatment for Depression, Bipolar Disorder, Schizophrenia, Alzheimer’s or Dementia?
*
Yes
No
Which condition?
*
Have you ever been confined to a hospital, long term care, or nursing facility?
*
Yes
No
When was the last time? Reason?
*
Back
Next
2. Medications
Beyond the health questionnaire, the biggest determining factors of qualifying for burial insurance is what’s on your pharmacy report.As a licensed field underwriter, I know what medications burial insurance companies will and won’t take.Please list all medications and dosages here. If you have to, please go to your medicine cabinet and provide all the information below.
Back
Next
3. Financial
Almost done! Please answer these last 4 financial questions to determine which company will be the most suitable for your situation.
Do you have any active burial or life insurance inforce?
*
Yes
No
What Amount? What Company? Monthly Payments? Will this replace any coverage or add on to it?
*
Do you have a valid checking or savings account in the US?
Yes
No
Will anyone other than yourself be paying for this program?
Yes
No
Back
Next
4. Submit
Submit the pre-qualification questionnaire.
Submit
Should be Empty: