Burial Insurance Quote
Coverage between $2,000- $40,000.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Male
Female
What's your date of birth?
What's your state and zip code?
Who do you want leave money to?
Spouse
Sibling
Children
Other
How much coverage do you want?
$5,000
$10,000
$15,000
$20,000
$40,000
How would you rate your current health?
Great. No health issues
Minor issues- one to two prescriptions
Currently recovering from sickness or accident
Serious challenges-more than 8 medications
Do you have any of these health issues?
1. Are you currently:(a) bedridden or confined to any hospital, nursing home, long-term care facility or skilled nursing facility;or receiving or been advised to receive care in a nursing home, hospice care, or home health care? (b) requiring assistance with activities of daily living such as taking medications, bathing, dressing, eating,toileting, getting in and out of a chair or bed, or control of bowel or bladder problems? (c) requiring any of the following (other than for fractures, bone or joint surgery, including replacement):wheelchair, electric scooter, or oxygen equipment to assist breathing (excluding use for sleep apnea)? . .
2. Have you ever been:(a) diagnosed as having Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC),or Human Immunodeficiency Virus (HIV) Infection (symptomatic or asymptomatic) or been treated for AIDS, ARC, or HIV by a physician or heath care provider? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(b) diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for Alzheimer’s Disease, Dementia, Huntington’s Disease, Sickle Cell Anemia, Myelodysplastic Syndrome (MDS), Lou Gehrig’s Disease (ALS), Quadriplegia, Paraplegia, Down’s Syndrome, mental incapacity, congestive heart failure,Cirrhosis, Metastatic Cancer or recurrent Cancer of the same type? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(c) diagnosed with insulin shock, diabetic coma, or had an amputation due to diabetic complications or diagnosed with End Stage Renal Disease or requiring dialysis?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(d) advised to receive or have received an organ or bone marrow transplant?. . . . . . . . . . . . . . . . . . . . . . . . .(e) diagnosed by a physician or health care provider as having a terminal medical condition that is expected to result in death within the next twelve 12 months?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. In the past 12 months, have you been:(a) advised by a physician to have a surgical operation, diagnostic testing other than for routine screening purposes or for those related to HIV/AIDS, treatment, hospitalization, or other procedure which has not been done or for which results are not known? (b) diagnosed by a physician or health care provider as having heart disease or heart surgery of any kind?
4. In the past 2 years, have you been diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for any form of cancer (except basal or squamous cell skin cancer)?
5. I don't have any of the above health issues
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