In the past twelve (12) months, have you used any form of tobacco or nicotine?
*
YES
NO
Have you tested positive or been diagnosed by a physician as having HIV or AIDS?
*
YES
NO
Has a physician diagnosed you with a life expectancy of twelve (12) months or less?
*
YES
NO
Are you currently bedridden, hospitalized, in a care facility (nursing home), or receiving hospice care?
*
YES
NO
Back
Next
Unfortunately, based on the answers you selected, your application will be declined for coverage.
Please select "back" and review your answers if you feel this is a mistake.
Back
Next
In the past two (2) years, have you been diagnosed with, been treated by a physician, or taken medication for any of the following conditions:
*
Back
Next
Requested Coverage
*
Please Select
$3,000
$5,000
$7,000
$10,000
$12,000
$15,000
$18,000
$20,000
Who will be your beneficiary?
*
Please Select
Aunt
Brother
Brother-in-Law
Business Partner
Caregiver
Child
Clergy
Common Law Spouse
Cousin
Daughter
Daughter-in-Law
Domestic Partner
Estate
Ex-Spouse
Executor
Father
Father-in-Law
Fiance(e)
Friend
Godchild
Godparent
Grandchild
Grandparent
Great Grandchil
Great Grandparent
Guardian
Husband
Mother
Mother-in-Law
Nephew
Niece
Other
Partner
Power of Attorney
Sibling
Sister
Sister-in-Law
Son
Son-in-Law
Spouse
Stepbrother
Stepdaughter
Stepfather
Stepmother
Stepsister
Stepson
Trust
Uncle
Wife
Back
Next
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Please Select
Male
Female
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
State & Zipcode
*
Street Address
Street Address Line 2
City
Please Select
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
State
Zip Code
Today's Date
/
Month
/
Day
Year
Date
Age
Plan Type
Level Plan
2-Year Modified Plan
3-Year Modified Plan
Submission Date / Time
*
/
Month
/
Day
Year
Date
Hour Minutes
Final Expense
Modified
Results
$3,000
$5,000
$7,000
$10,000
$12,000
$15,000
$18,000
$20,000
Non-Tobacco - Level
FEMALE-NT3
FEMALE-NT5
FEMALE-NT7
FEMALE-NT10
FEMALE-NT12
FEMALE-NT15
FEMALE-NT18
FEMALE-NT20
MALE-NT3
MALE-NT5
MALE-NT7
MALE-NT10
MALE-NT12
MALE-NT15
MALE-NT18
MALE-NT20
Tobacco - Level
FEMALE-TB3
FEMALE-TB5
FEMALE-TB7
FEMALE-TB10
FEMALE-TB12
FEMALE-TB15
FEMALE-TB18
FEMALE-TB20
MALE-TB3
MALE-TB5
MALE-TB7
MALE-TB10
MALE-TB12
MALE-TB15
MALE-TB18
MALE-TB20
Modified
FEMALE-MOD3
FEMALE-MOD5
FEMALE-MOD7
FEMALE-MOD10
FEMALE-MOD12
FEMALE-MOD15
FEMALE-MOD18
FEMALE-MOD20
MALE-MOD3
MALE-MOD5
MALE-MOD7
MALE-MOD10
MALE-MOD12
MALE-MOD15
MALE-MOD18
MALE-MOD20
Back
Next
Unfortunately, based on your date of birth, you are not eligible for a policy from us. Our plans insure to Age 85.
Please select "back" and review your answers if you feel this is a mistake.
Back
Next
Quote Agreement
By clicking “Submit”, I expressly consent by electronic signature to receive marketing communication, including via calls using an automatic telephone dialing system and artificial or pre-recorded messages, emails, and text messages (SMS), from ShieldPolicy or their agents/representatives to the phone number provided (including any wireless numbers). I understand that my consent to receive communications in this manner is not required as a condition of purchasing any goods or services, my telephone company may impose charges for these contacts, and I can revoke my consent at any time. By clicking “Submit”, I further agree to receive SMS notifications from ShieldPolicy, its agents, affiliates, or partner companies. Message and data rates may apply. Message frequency varies. You may receive alerts until you choose to opt out of this service by texting “Stop” or replying “Stop” to any of our messages. By submitting your information, you agree to be contacted even if you are on any internal, state or national “Do Not Call” list.
Submit
Should be Empty: