IMPORTANT MESSAGE FOR RESIDENTS OF NEW YORK
Pursuant to New 11 NYCRR § 229.5(b) and 3 NYCRR § 405.6(b)(4)
LifeQuotes is giving you the below information and link to the State of New York Executive Order as follows:
New York Governor, Andrew M. Cuomo issued Executive Order 202.13 and the emergency adoption of 11 NYCRR 229 (INSURANCE REGULATION 216) INSURER PRACTICES DURING THE COVID 19 PANDEMIC by the New York State Department of Financial Services (DFS).
In order to assist policyholders impacted by the COVID 19 pandemic, Executive Order 202.13 and Regulation 216 requires insurers to take specific actions to alleviate the adverse impact caused by the pandemic on policyholders who can demonstrate financial hardship. Specifically, to extend to 90 days the grace period for the payment of premiums and fees, and for the exercise of rights, under life insurance policies and annuity contracts.
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Coverage Amount
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How much coverage do I need?
If you are an employed family income breadwinner with minor
children, financial planners suggest carrying a minimum of
ten times your annual income. If you are a non-working
caregiver at home with minor children, we suggest at least
$150,000. If you are an adult looking for burial coverage
only, we suggest $5,000 to $25,000.
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Health, financial and lifestyle items that can affect your life insurance rate
Birth Date (Ages 14 Days
- 85 Years)
Weight with clothes on
Use
higher of current or from last doctor visit
(OK to
apply ½ of weight loss in last year)
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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.
Have you used any tobacco, nicotine, marijuana, vape, e-cigarette or tobacco substitute in the last 5 years?
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Why do life insurers ask about
this?
Nicotine use of any kind, as well as marijuana use, is
looked at very closely by all life insurers. Smoking,
chewing, inhaling in a vaporized form, consuming in edible
products, or 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.
Indicate last tobacco, nicotine, marijuana, vape or tobacco substitute use:
Do you now (or have you in the last year) worked at a paying job (employed or self-employed) 20 or more hours per week?
Please check any of the following that apply to you:
Are you now receiving
disability payments from any source?
For what illness or
injury are you receiving disability payments?
Are you now receiving
any form of government assistance such as food stamps, WIC
or Medicaid?
Have you had a bankruptcy discharged or established a bankruptcy repayment plan in the last 12 months?
What type of immigrant visa do you
have?
Please provide the purpose of your planned foreign travel,
location(s) to be visited, and number of days expected in coming
year.
Check the activity(ies) that you participate in:
Do you fly as a pilot or crew member?
Total number of hours flown as a pilot
Do you have a valid FAA Medical Certificate?
Class of FAA Medical certificate held
Date of last FAA medical exam
Was the medical certificate issued under special issuance or with any restrictions?
Special issuance or restriction?
Do you have a valid FAA Airman Certificate?
Do you have an Instrument Flight Rating?
Have you ever been in an aircraft accident, grounded, fined, reprimanded or had your license revoked?
Date license was obtained:
What is the make and model of the primary aircraft that you currently fly?
Are you a member of any branch of the military (including Reserves or National Guard)?
Type of aircraft in service:
How long have you flown this type of aircraft?
Do you ever fly from an aircraft carrier?
Is all aviation activity conducted in the United States or Canada?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying as a pilot?
Type of flying as a pilot
Hours expected over next 12 months:
Please explain specifically what type of flying you engage in as a pilot:
Describe duties as a crew member aboard the aircraft:
What is the make and model of the primary aircraft that you are a crew member of?
Flight time as crew member in hours:
Do you expect to make
more than 10 dives in the next 12 months?
What is the maximum depth
to which you will dive?
Are you a certified dive
instructor or professional diver?
Do you participate in any
technical or high risk dives, including but not limited to
cave, ice, or salvage diving?
Please specify the type of climbing, years of
experience, average heights, degree of difficulty, and other
details related to your mountaineering and/or rock climbing.
Please specify the type of racing, years of
experience, type of vehicle and track, and other details
related to your motorized racing activities.
Please specify the exact type of activity and
other details related to the potentially hazardous sport or
activity in which you participate.
In what year was the criminal conviction or law enforcement infraction?
Please provide details of the conviction or infraction (charge(s), state, time served, etc.).
If you need to list a second incident, in what year did it occur?
Please provide details of the conviction or infraction (charge(s), state, time served, etc.).
In what year was the most recent moving violation?
Please provide details of the conviction or infraction (charge(s), state, time served, etc.).
If you need to list a second incident, in what year did it occur?
Please provide details of the conviction or infraction (charge(s), state, time served, etc.).
If you need to list a third incident, in what year did it occur?
Please provide details of the conviction or infraction (charge(s), state, time served, etc.).
If you need to list a fourth incident, in what year did it occur?
Please provide details of the conviction or infraction (charge(s), state, time served, etc.).
What was the name of the insurance company you were rated up or declined by?
What was the approximate
date of your application?
Were you declined or
rated up (approved for a higher premium than you applied
for)?
What was the reason given
for the decline or rate-up?
Has there been any
incidence of cardiovascular, heart or coronary artery
disease, or stroke in any parent or sibling prior to age
60?
Please check the applicable
family member(s) and incidence(s):
• Cardiovascular diagnosis before age 60
• Cardiovascular death before age 60
Has there been any
incidence of cancer, other than basal or squamous cell skin
cancer, in any parent or sibling prior to age 60?
If you
have multiple family members to list, start with any parent.
What was the type of cancer?
Did this family member
pass away from the cancer?
List another familial
cancer incidence?
Second
Familial Cancer Incidence
What was the type of cancer?
Did this family member
pass away from the cancer?
List another familial
cancer incidence?
Third
Familial Cancer Incidence
What was the type of cancer?
Did this family member
pass away from the cancer?
List another familial
cancer incidence?
Fourth
Familial Cancer Incidence
What was the type of cancer?
Did this family member
pass away from the cancer?
You've indicated that you
have an outstanding medical test or procedure that is not
yet completed. We'll show you quotes, but please click Yes
to indicate your understanding that those tests will have
to be completed before you apply for more than $30,000 of
regular life insurance.
In the past 10 years, have you had or been treated for any of the
following conditions?
Do you recall your last blood pressure reading?
Do you recall your last
total cholesterol reading and cholesterol HDL ratio?
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Alcohol Abuse Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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| Asthma Questionnaire
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is under control or if it restricts normal life in any way: |
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Drug Abuse Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Gastric/Peptic Ulcers Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Recurrent Kidney Stones Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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For what medical conditions have you EVER been diagnosed, treated or
prescribed any medication?
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Psoriatic or Rheumatoid Arthritis Questionnaire
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| Have you ever
had any of the following occurrences or symptoms? |
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| Please check
functional ability: |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Vascular / Heart Disease or Abnormal EKG Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Breast Cancer Questionnaire
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| What was the stage of
the cancer? |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Leukemia Questionnaire
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select type of leukemia: |
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| Have any of
the following tests been done? If so, please give date and
results: |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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| Please provide
the results of your most recent CBC (complete blood count): |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Melanoma Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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| Prostate Cancer Questionnaire |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Skin Cancer Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Cancer Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Colitis / Ileitis Questionnaire
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| Please note the type of
inflammatory bowel disease present: |
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| Please check if you have had: |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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COPD Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Crohn's Disease Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Anxiety/ADD/Depression/Mental Illness Questionnaire |
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| Diabetes Questionnaire
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| What type of Diabetes? |
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| What was your most
recent hemoglobin A1c? |
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| What was your most
recent blood sugar reading? |
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| The diabetes is
controlled by: |
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| Please check if you have
had any of the following: |
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| Describe how well this
condition is under control or if it restricts normal life
in any way: |
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Emphysema Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Epilepsy Questionnaire
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Please note type of seizure:
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Chronic Pain / Fibromyalgia Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Gout Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Hepatitis/Liver Disease Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Hypothyroidism Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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| Kidney Disease Questionnaire
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| Please provide
the your most recent readings for: |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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| Please provide
the most recent results of the following kidney function
tests: |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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| Please give
the date and results of the most recent urinalysis: |
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| If any of the
following urinary tests have been completed, please give
the date and result: |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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| Please provide
the date and results of your most recent urinalysis. |
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| Please provide
the date and results of the most recent kidney function
tests. |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Lupus Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Mitral Valve Prolapse Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Multiple Sclerosis Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Parkinson's Disease Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Prostate Issues (no cancer)
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Sarcoidosis Questionnaire
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| What organs
were involved? |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Sleep Apnea Questionnaire
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| Was the sleep
apnea diagnosed as: |
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| How is the
sleep apnea being treated? |
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| Please check if
you have had any of the following: |
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Stroke Questionnaire
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| Describe how well this condition
is under control or if it restricts normal life in any way: |
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Do you have any health
conditions or non-medical situations that have not already been
disclosed?
What was the medical condition?
List any medications used in
treatment of this condition along with the dosage:
What was the date of diagnosis?
List any additional medical
condition if applicable:
List any medications used in
treatment of this condition along with the dosage:
What was the date of diagnosis?
List any additional medical
condition if applicable:
List any medications used in
treatment of this condition along with the dosage:
What was the date of diagnosis?
For ages under 18 years, maximum Coverage Amount available is $75,000.
