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Coverage Amount
How much coverage do I need?
We recommend that each household breadwinner carry ten times their annual income in total life insurance. Caregiving adults who are responsible for others should consider $300,000. 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 
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.
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.
Height 
Lifestyle questions that can affect your 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 established?
No Yes
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 or a permanent legal U.S. resident/green card
holder?
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 1-800-324-6370 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 rate
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
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