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Coverage Amount
How much coverage do I need?
If you are a family breadwinner with dependents, financial planners suggest carrying ten times your annual income. If you are a non-working caregiver at home, we suggest your choice of $150,000 to $500,000. If you are looking for burial coverage only, we suggest $5,000 to $25,000. If you need personalized advice, call our life insurance counselors at 1-800-410-0733 or click here to view our online life insurance needs calculator.
State of Residence 
Check box if living abroad 
Birth Date
(Ages 14 Days - 85 Years)
Sex Male Female 
Any tobacco, nicotine or
marijuana use?
Why do life insurers ask about this?
Nicotine use of any kind, including marijuana use, is looked at very closely by all life insurers. Smoking, chewing, inhaling in a vaporized form, consuming in edible products, and wearing a patch on the skin, all constitute use of these products. Non-admittance of marijuana use can result in a decline. Sources of information the insurer may use include: statements made on your application, telephone interviews, your paramed exam results (if one is required), your outside medical records and your Medical Information Bureau (MIB) profile. If you currently use marijuana AND any product containing tobacco or nicotine, please select the response that most closely describes your tobacco or nicotine use. Always be 100% honest when you answer tobacco use questions to ensure accurate quotes. Remember, a false statement on an application for insurance could void your coverage. If you need personalized advice, call our life insurance counselors at 1-800-410-0733.
Height & Weight
 Weight(with clothes on)
Why does the life insurance company need to know your actual weight?
Weight (with clothes on) is a key rating factor with all life insurance companies. Please give an honest answer here so that you can receive accurate rate quotes. And keep in mind that the paramed examiner who visits you will be carrying a portable scale, so be honest here.
Lifestyle questions that can affect your Life Insurance rate
Did you think that life insurance companies look only at your health history? Not true. Today, life insurance companies look just as closely at many non-medical aspects as they do at your health. Items looked at very closely include disability, receiving government benefits, open bankruptcy, U.S. citizen status, hazardous activities such as mountain climbing or racing, intended foreign travel to dangerous countries, private pilot intentions, scuba diving habits, driving and criminal record status. In order to receive an accurate rate quote, always be honest in your answers to these questions.
Are you now receiving disability payments from any source? No Yes
Are you now receiving any form of government assistance
such as Food Stamps, WIC or Medicaid?
No Yes
Do you currently have a personal bankruptcy filing that has
not been discharged or does not yet have a repayment plan
No Yes
Excluding scuba diving, do you intend to engage or participate
in any hazardous activities, occupations or travel to any country
shown on the U.S. State Department's Travel Warnings list?
No Yes
Do you intend to fly as a Private Pilot? 
Why am I being asked about private pilot intentions?
All life insurers ask about your intentions to pilot or act as a crew member on any private aircraft, which also includes balloons and gliders. Private pilots who wish to have life insurance coverage in force while they are piloting a private aircraft are normally asked to complete an Aviation Questionnaire as a routine part of underwriting. Our life insurance counselors are skilled and experienced at helping private pilots obtain life insurance at the lowest possible rates, so please call us at 1-800-410-0733 if you have any questions or need assistance.
No Yes
Do you intend to participate in scuba diving? No Yes
Within the last 5 years, have you been convicted of either
reckless driving or driving while under the influence, received
3 or more moving violations or had your license suspended or
revoked, had any other convictions, law enforcement infractions
of any kind or been on parole or probation?
No Yes
Family & Health questions that can affect your Life Insurance rate
Have you bought a personal (not work-related or group) term
life insurance policy that required a paramedical exam within
the last 60 months?
No Yes
Are you a U.S. Citizen? No Yes
Have any of your parents or siblings (biological only), prior to age 60,
been diagnosed with or died from:
• Cardiovascular, heart or coronary artery disease, or stroke? No Yes
• Cancer, other than basal or squamous cell skin cancer? No Yes
Do you have any pre-existing medical conditions or
currently take prescription drugs for any medical condition?
No Yes
Do you recall your last blood pressure reading?
Why am I being asked about my blood pressure?
Hypertension, also called "elevated blood pressure" or "high blood pressure", is looked at closely by all life insurance companies. If you don't remember your last readings, it's OK to choose "I don't know" as your answer. In that case, we'll assume that you do not have a history of hypertension and we will show you the lowest possible rates. If you choose a plan that requires a paramedical exam, which is really a face-to-face interview or "mini-medical" then our technician will check your blood pressure at that time. If you need personalized advice or help, call our insurance counselors at 1-800-410-0733.
Are you taking blood pressure medication? No Yes
Do you recall what your last cholesterol ratio was?
Do you recall what your last cholesterol level was?
Are you taking cholesterol medication? No Yes
Have you ever been rated up or declined by any life insurance
No Yes
Has any doctor recommended any medical test or procedure
that you have not yet completed?
No Yes
In the past 10 years, have you had or been treated for any of the following conditions?
 Alcohol Abuse  
 Anxiety, ADD or ADHD  
 Drug Abuse or Addiction  
 Gastric/Peptic Ulcers  
 Recurrent Kidney Stones
For what medical conditions have you EVER been diagnosed, treated or prescribed any medication?
 Artery (Coronary) Disease  
 Arthritis (Psoriatic or Rheumatoid)
 Colitis or Ileitis  
 Crohn's Disease  
 Depression or Mental Illness  
 Heart Disease or Abnormal EKG  
 Hepatitis or Liver Disease
 Kidney Disease
 Mitral Valve Prolapse  
 Multiple Sclerosis
 Pain (Chronic & Ongoing)  
 Parkinson's Disease  
 Prostate Issues (no cancer)
 Sleep Apnea  
 Vascular Disease  
Have you been diagnosed with any other health conditions
not listed above?
No Yes
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