Life Insurance Questionnaire

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State of Residence* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansa
California
Colorado
Connecticut
Delaware
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
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Gender* This field is required.
Female
Male
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Date of Birth* This field is required.
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Coverage Amount* This field is required.
$500,000
Please Select
Less Than $25,000
$25,000
$50,000
$75,000
$100,000
$125,000
$150,000
$175,000
$200,000
$225,000
$250,000
$275,000
$300,000
$350,000
$400,000
$450,000
$500,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
$5,000,000
$5,500,000
$6,000,000
$6,500,000
$7,000,000
$7,500,000
$8,000,000
$8,500,000
$9,000,000
$9,500,000
$10,000,000
Other Amount
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Insurance Type* This field is required.
Please Select
Please Select
Term Life Insurance
ROP-Return of Premium Term Life
Universal Life Insurance
Whole Life Insurance
Not Sure Yet
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Term Length
Please Select
Please Select
Not Sure Yet
5 Year Term
10 Year Term
15 Year Term
20 Year Term
25 Year Term
30 Year Term
Greater Than 30 if Available
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Do You Currently Have Life Insurance?* This field is required.
Yes
No
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Are You Looking to Replace This Policy?
Yes
No
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Have your parents or siblings had heart disease, cancer or stroke prior to age 60?* This field is required.
Yes
No
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If Yes, please indicate family member, diagnosis, age of diagnosis and/or age at death, or please provide current age if still living
12
Have you had more than 1 moving violation in past 3 years* This field is required.
yes
No
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How Many Moving Violations
2 in past 3 years
3 in past 3 years
4 in past 3 years
More than 4 in past 3 years
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Has Your Drivers License Been Suspended in Past 10 Years?* This field is required.
Yes
No
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Why, When and for How Long Suspended?
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Do You Do Any of the Following:* This field is required.
Scuba Diving
Private Pilot
Motorized Racing
Skydiving/Parachuting
Mountain/Rock Climbing
Regular Ballooning
I have not done any hazardous activities in past 2 years, nor do I expect to in next 2 years
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Height* This field is required.
Please Select
Please Select
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"
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Weight (in pounds)* This field is required.Insurance companies like to see a stable weight for 12 full month's since they know people try to drop weight prior to applying for insurance
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Do You Smoke or Use Tobacco Or Nicotine in ANY form?* This field is required.
Please Select
Please Select
Never
Cigarette Smoker
Quit Smoking
E-Cigarette
Cigar-Celebratory Cigar
Cigar-Occasional
Cigar-Daily
Chewing Tobacco
Use More Than 1 Type Tobacco
Marijuana
Other Nicotine Products
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How Long Since You Quit?Did you know that most companies will consider you to be a smoker for 12-24 months after you quit...It is also important to note that the non-smoker rate classes will vary by company and time since you quit.
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What Do You Use?
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Do You Take Any Medications?* This field is required.
Yes
No
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Please include medication name, dosage and frequency takenDon't worry if you do not have exact spelling. It's most important from underwriting standpoint to know why you are taking something.
24
Ever been diagnosed with or treated for any of the following?
Heart Disease
Diabetes
Cancer
Stroke, TIA or Mini Stroke
Depression, Anxiety, Other Mental Health
Kidney Disease
Liver Disease
Sleep Apnea
Alcohol/Substance Abuse
Autoimmune or Autoinflammatory Disorder
Asthma, COPD or other Respiratory Disease
Alzheimer's or Dementia
Currently Disabled
Other Medical Issue in Medical Records
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Please Provide Details To Above
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Any Other Info You'd Like to Provide That Could Help Us To Get You A Better Offer:
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Name* This field is required.
First Name
Last Name
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E-mail* This field is required.
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Phone number (not required, please provide if you prefer call or text)
Area Code
Phone Number
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Address (not required)
Street Address
Unit/Apartment Number
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Unique ID Number
Should be Empty: