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Coverage Amount: Close 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. If you need personalized advice, call our life insurance counselors at 1-800-324-6370 or click here to view our online life insurance needs calculator.		Life Insurance Needs Calculator
State of Residence:		Check box if living abroad:
Birth Date: (Ages 14 Days - 85 Years)
Sex:	Male Female
Tobacco or nicotine use? Why do life insurers ask about tobacco use history? All life insurers ask about and rate for tobacco use, including any history of cigarette, pipe, chew, patch or gum, so please be 100% honest when you answer this question so that you can receive accurate rate quotes. Sources of information include your application statements, your paramed exam results, your outside medical records and your Medical Information Bureau (MIB) file. And remember, a false statement on an application for insurance could void your coverage. If you need personalized advice, call our life insurance counselors at 1-800-324-6370.
Height:	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. If you need personalized advice, call our life insurance counselors at 1-800-324-6370.

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

Choose One:
I am in good health and have taken no prescription drugs over past 5 years.
New! Show me custom quotes based upon my own health history and lifestyle.

Have you received disability benefits or any form of government assistance within the last 6 months?

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

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/revoked or had any other convictions or law enforcement infractions of any kind?

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

Do you intend to participate in scuba diving?

No Yes

Do you intend to: travel to any country shown on the U.S. State Department's Travel Warnings list, mountain climb, rock climb, skydive, race a motorized vehicle, or engage in any hazardous activity; or do you have a history of any criminal conviction that we should know about in order to give you an accurate quote?

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 1-800-324-6370.

Are you taking blood pressure medication?

No Yes

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 company?

No Yes

How many doctors or health care professionals have
you seen in the last 5 years?

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, ADHD or Depression	Asthma
Cancer (Skin Only)	Drug Abuse or Addiction	Gastric/Peptic Ulcers
Recurrent Kidney Stones

Gastric/Peptic Ulcers Questionnaire

Please list date when first diagnosed:

Please note how the ulcer was treated:

Medications only

Surgery only

Both

Have there been any recurrences or more than one episode?

No Yes

Are you on any medications?

No Yes

Any other major illnesses; for example, cancer, diabetes or heart disease?

No Yes

Comments:

Recurrent Kidney Stones Questionnaire

Please list date when first diagnosed:

Date of most recent attack:

How many episodes have you had?

How many total stones have there been?

Have you ever been hospitalized for this condition?

No Yes

Has any special testing been done, such as kidney function tests?

No Yes

Please list the type of treatment received:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No Yes

Comments:

Have you been diagnosed with any other health
conditions not listed above?

No Yes

Crohn's Disease Questionnaire

Date of first diagnosis:

Ever had any of the following occurrences or symptoms?

Hospitalizations for this disorder (list dates)	List Dates:
Surgery for this disorder (list dates)	List Dates:
Colonoscopy (list dates of most recent)	List Dates:

List all medications being taken (prescription and/or non-prescription)?

Any other major illnesses; for example, cancer, diabetes or heart disease?	No Yes
Details:

Comments:

Multiple Sclerosis Questionnaire

Please list date of first diagnosis:

Please indicate the number of episodes and date of last episode:

Are you on any medications?

No Yes

Please note current neurologic status and/or symptoms.

normal	minimal residual impairment
moderate residual impairment	severe residual impairment

Please provide all MRI brain scan reports:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No Yes

Comments:

Colitis / Ileitis Questionnaire

Please list date of first diagnosis:

Please note the type of inflammatory bowel disease present:

Chronic Ulcerative Colitis

Chronic Proctitis (inflammation in rectum only)

Are you on any medications?

No Yes

Please check if you have had:

hospitalizations for this disorder (list dates)	List Dates:
surgery for this disorder (list dates)	List Dates:
colonoscopy (list dates of most recent)	List Dates:

Any other major illnesses; for example, cancer, diabetes or heart disease?

No Yes

Comments:

Fibromyalgia Questionnaire

Date when first diagnosed:

Is the pain localized or widespread?

Are you taking any medication?	No Yes
If yes, which?

Do you have any disabilities or physical impairments?	No Yes
If yes, please provide details:

Do you have a history of mental illness?	No Yes
If yes, please provide details:

Do you drink alcohol?	No Yes
If yes, how much and how often?

Comments:

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Quote & Buy Online in Total Privacy

Now Quoting Guaranteed Acceptance (no medical question) Plans

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America's top life insurance companies

Instant Life Insurance Quotes

Compare rates of 50 leading Life Insurance companies in seconds

Compare rates of 50 leading Life
Insurance companies in seconds