Life Simple Form
Proposed Insured Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you want to receive notification through SMS?
*
SMS Opt-in
SMS Opt-out
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Please Select
Male
Female
Non-Binary
Height
*
Weight
*
Preferred Contact Method
*
Please Select
Email
Call
Text
Do you or have you ever used tobacco?
*
Yes
No
Quantity
*
(i.e. 1 pack or half a pack)
Frequency
*
(i.e. per day or per week)
Form
*
(i.e. cigarettes, chew, vape)
Last Used
*
(i.e. month, year)
Have you used marijuana in the last 5 years? (Don't worry, you're still insurable)
*
Yes
No
Have you seen a doctor in the last 5 years?
*
Yes
No
Please indicate the approximate date and the reason for the visit
*
Are you taking any prescribed medications?
*
Yes
No
Please list all currently prescribed medication outside of a common prescribed antibiotic in the last 5 years
*
Format: Medication Date - Medication Name - Dosage - Reason
Have any immediate family members (parents and/or siblings) passed away prior to the age of 60 due to cancer, diabetes, or cardiovascular disease?
*
Yes
No
Any moving violation including but not limited to driving under the influence (DUI) under the last 5 years?
*
Yes
No
Please provide details
*
Any private pilot activity in the last 3 years or planned for the future?
*
Yes
No
Any past travel in the last 2 years or future plans in the next 2 years to travel outside of the U.S.?
*
Yes
No
Please provide details
*
Are you a citizen or legal resident of the U.S.?
*
Yes
No
Submit
Should be Empty: