Life Simple Form

1

Proposed Insured Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Date of Birth* This field is required.

Date

5

Sex* This field is required.

6

Height* This field is required.

7

Weight* This field is required.

8

Preferred Contact Method* This field is required.

9

Do you or have you ever used tobacco?* This field is required.

Yes

No

10

Quantity* This field is required.

(i.e. 1 pack or half a pack)

11

Frequency* This field is required.

(i.e. per day or per week)

12

Form* This field is required.

(i.e. cigarettes, chew, vape)

13

Last Used* This field is required.

(i.e. month, year)

14

Have you used marijuana in the last 5 years? (Don't worry, you're still insurable)* This field is required.

Yes

No

15

Have you seen a doctor in the last 5 years?* This field is required.

Yes

No

16

Please indicate the approximate date and the reason for the visit* This field is required.

17

Are you taking any prescribed medications?* This field is required.

Yes

No

18

Please list all currently prescribed medication outside of a common prescribed antibiotic in the last 5 years* This field is required.

Format: Medication Date - Medication Name - Dosage - Reason

19

Have any immediate family members (parents and/or siblings) passed away prior to the age of 60 due to cancer, diabetes, or cardiovascular disease?* This field is required.

Yes

No

20

Any moving violation including but not limited to driving under the influence (DUI) under the last 5 years?* This field is required.

Yes

No

21

Please provide details* This field is required.

22

Any private pilot activity in the last 3 years or planned for the future?* This field is required.

Yes

No

23

Any past travel in the last 2 years or future plans in the next 2 years to travel outside of the U.S.?* This field is required.

Yes

No

24

Please provide details* This field is required.

25

Are you a citizen or legal resident of the U.S.?* This field is required.

Yes

No