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the lowest life insurance rates available
Coverage Amount
Close
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.
$25 Million
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$1.25 Million
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$1.1 Million
$1 Million
$ 950,000
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$ 5,000
Coverage Estimator Tool
ZIP Code
Health, financial and lifestyle items that can affect your life insurance rate
Birth Date
(Ages 14 Days - 85 Years)
Month
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
Day
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
09
08
07
06
05
04
03
02
01
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
Gender
Male
Female
Any tobacco, nicotine, marijuana, vape or tobacco substitute use?
Close
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.
Select...
Never
None in the last 5 years
None in the last 4 years
None in the last 3 years
None in the last 2 years
None in the last year
Last 12 mos: cigarettes, more than 24 per year
Last 12 mos: cigarettes, 24 or fewer per year
Last 12 mos: vape or e-cigarettes
Last 12 mos: nicotine replacements (gum, patch, etc.)
Last 12 mos: cigar use, 1 or fewer per month/12 or fewer per year
Last 12 mos: cigar use, more than 1 per month
Last 12 mos: chewing tobacco, pipe or snuff
Last 12 mos: marijuana use, 2 or fewer times per month
Last 12 mos: marijuana use, more than 2 times per month
Height
feet
inches
Weight with clothes on
Use higher of current or from last doctor visit
(OK to apply ½ of weight loss in last year)
Close
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.
lbs.
Do you work at a paying job (employed or self-employed) at least 30 hours per week?
Yes
No
Occupation:
Enter Occupation (Search By Typing)
Unknown or not listed
Account Executive
Accountant (College Degreed)
Accountant (CPA)
Accountant (No College Degree)
Actor/Actress
Actuary ( w/out FSA)
Actuary (FSA)
Acupuncturist
Administrative Assistant
Advertising Representative
Aerobics / Exercise Instructor
Aeronautical Engineer
Aesthetician
Air Conditioning Engineer (office and consulting only)
Air Conditioning Engineer (superintending and inspecting)
Air Conditioning Installer, Repairman, Servicemen
Air Evacuation Personnel
Air traffic Controller
Aircraft Groundcrew
Aircraft Pilot (as a career)
Airport Dispatcher
Airport Manager (office and supervisor only)
Airport Operations Clerk, Passenger Agent
Airport Reservations Clerk
Alarm Installer / Repair
Algologist
Allergist / Immunologist
Ambulance Driver
Analyst
Anchorman
Anesthesiologist
Anesthetists
Announcer (Radio / TV)
Announcer (Radio-TV - on site in USA)
Announcer (Radio-TV-inside duties)
Antenna or Tower Worker
Anthropologist
Antique Dealer (Purchasing, Repairing, Collecting or Delivering)
Antique Dealer (Sales Only)
Appliance Repair
Appraiser
Appraiser ( Art Goods-Jewelry)
Arbitrageur
Architect
Architect (Landscape Design)
Armored Car Driver / Worker
Art Director
Art Gallery Owner
Art Restorer
Artist or Graphic Artist (full time salaried)
Asbestos Remover / Pipewrapper
Asphalt Worker
Assayers (not in mine)
Assembly Line Worker
Assessors
Astronomer
Athlete (Pro or Semi-Pro)
Athletic Director
Attendant (Hospital, nursing home)
Attendant (Parking)
Attorney
Auctioneers
Audio Visual Tech
Audiologist
Auditor
Auto Body Shop Employee
Auto Body Shop Owner (no labor)
Auto Dismantler
Auto Garages, Filling & Service Stations, Proprietors and Managers
Auto Repairmen, Painters, Bodymen, Mechanics
Automobile Dealership Owner (Multiple Dealerships)
Automobile Industry - Salesmen (new vehicles), Dealers, Dealership Owners
Bacteriologist
Baggage Handler
Bail Bondsman (Owner, office only)
Bakery - All Others
Bakery Managers, Proprietors
Bank Guard / Watchman
Bank Loan Officers
Bank Manager / Officer
Bank Portfolio Managers
Bank Teller & Clerk
Banquet Manager
Bar Owner / Nightclub Owner
Bar Worker / Nightclub Worker
Barber
Bartender
Beautician
Bell Boy / Doorman
Bench Worker (Skilled)
Billboard Worker
Biochemist
Biologist
Blacksmith
Boat Builder Worker
Boat Sales
Body Shop Employee
Body Shop Owner (no labor)
Bodyguard
Bond Broker
Bond Traders (No floor trading)
Bookbinder
Booking Agents (full-time, office away from home)
Bookkeepers
Boom Operator
Botanist (office duties only)
Brewery Manager
Brewery Supervisor
Brewery Worker (no assembly line)
Bricklayer
Bridge Worker
Building Inspector
Building Manager (Supervisory Only)
Building Manager/Supervisor (Maintenance duties)
Burglar Alarm Installer/Repairer
Bus Boy
Bus Driver
Business Agent
Business Agent/Manager (Union)
Business Agent/Manager (Union, outside duties)
Business Owner
Butcher
Butler
Buyer (Furs, livestock or produce)
Buyer (Merchandise or equipment)
Cabinet Maker
Cable Worker (Not overhead)
Caisson Worker
Camera Operator (See special occupation section)
Camera Operator (Studio only, see special occupation section)
Camp Counselor
Camp Owner
Cantor (Clergy)
Car Sales (Non dealership)
Car Wash Employees
Car Wash Owner
Car Wash Proprietors and Managers
Cardiologist
Cardiovascular Surgeons
Carpenter
Carpet Installer
Cartographer
Cashier- Retail / Grocery
Cashier-Bank
Caterers (no food prep or serving, office and sales only)
CFO
Chauffeur
Check Cashing Employee
Check Cashing Owner (No Weapons)
Chef (First Class Restaurant)
Chemical Engineer
Chemical Worker (No Hazardous Materials)
Chemist
Chimney Sweep
Chiropractor
Cinematographer
Civil Engineer (Field Work)
Civil Engineer (Office Only)
Claims Adjuster (insurance) - fire or marine
Claims Adjuster (insurance) - not fire or marine
Claims Agent (Transportation)
Clergymen
Coach (Full Time)
Collection Agent ( No Repo)
College Dean (Private School)
Colon and Rectal Surgeon
Commercial Artist (Full Time)
Commodities Broker / Trader (Not on Floor)
Commodities Broker / Trader (On Floor)
Composer / Songwriter
Comptrollers
Computer / Software Analyst
Computer / Software Consultant
Computer / Software Engineer
Computer / Software Programmer
Computer Operator
Computer Repairman, Servicemen, Installers
Computer Sales (duties outside office)
Computer Sales (duties primarily inside home office)
Computer Technician
Concierge
Concrete / Cement Worker
Conductor (Salaried, symphony / studio)
Construction Foremen, Supervisors
Construction Owner/Contractor (executive duties only)
Construction Owner/Contractor/Estimators (supervising and on-site)
Consultants
Controller
Convenience Store Owner
Convenience Store Worker
Cook
Cosmetologist
Costume Designer
Counter Worker
Court Reporter
Crane Operator
Credit Reporter
Critical Care Physician
Crop Duster
Curator
Custodian
Customer Service Rep.
Cutter / Presser
Dairy Worker
Dance Instructor
Dancer
Day Care Worker
Dealer (Gambling)
Deli Owner / Manager
Deli Worker
Delivery Person
Demographers
Demolition Worker
Dental Assistants
Dental Hygienists
Dental Lab Workers, Technicians
Dentists (all specialties and residents)
Denturist
Dermatologist
Designer (In Office or Studio)
Designer (Industrial)
Diamond Broker
Diamond Cutter / Setter
Diemaker
Dietician (not preparing food)
Dietician (others)
Director
Disc Jockey
Dispatcher (No Manual Duties)
Diver
Diving Instructor
Dock Worker
Doctor - Allergist / Immunologist
Doctor - Anesthesiologist
Doctor - Cardiologist
Doctor - Cardiovascular Surgeons
Doctor - Colon and Rectal Surgeon
Doctor - Critical Care Physician
Doctor - Dermatologist
Doctor - Emergency Medicine Physician
Doctor - Endocrinologist
Doctor - Endodontist
Doctor - Family Practice Physician
Doctor - Gastroenterologist
Doctor - General Practice Physician
Doctor - Geneticist
Doctor - Genetics Physician
Doctor - Geriatrician
Doctor - Hospitalist Physician
Doctor - Neonatologist
Doctor - Nephrologist
Doctor - Neurologist
Doctor - Neurosurgeon
Doctor - Nuclear Medicine Physician
Doctor - Obstetrician and Gynecologist
Doctor - Oncologist
Doctor - Ophthalmologist
Doctor - Optometrist
Doctor - Oral Surgeon
Doctor - Orthodontist
Doctor - Orthopedic Surgeon
Doctor - Otolaryngologist
Doctor - Pain Management Physician
Doctor - Pediatrician
Doctor - Perinatologist
Doctor - Periodontist
Doctor - Plastic Surgeon
Doctor - Podiatrist (All Specialties)
Doctor - Preventive Medicine Physician
Doctor - Psychiatrist
Doctor - Pulmonologist
Doctor - Radiologist
Doctor - Respiratory Therapist
Doctor - Rheumatologist
Doctor - Surgeon (all specialties)
Doctor - Thoracic Surgeon
Doctor - Urologist
Domestic Service Worker
Door to Door Sales
Doorman
Drafter (office away from home)
Drilling Contractor
Driver (any vehicle)
Driving School Teacher
Drug / Pharmaceutical Detailing
Dry Cleaner
Dry Cleaning Clerks/Managers
Drywaller / Sheetrocker
Dyer / Bleacher
Ecologists
Economist
Editor (Journalism / Publishing)
Electrical Engineer
Electrical Technician (No Wiring)
Electricians
Electrologist
Electroplater
Elevator Installer / Repair
Elevator Operator
Embalmer
Emergency Medicine Physician
Employment Recruiter/Owner/Manager
EMT (Ambulance-No Driving)
EMT (Trauma Center, Inside Only)
Endocrinologist
Endodontist
Engineers (Office & Consulting Duties Only)
Engraver
Environmental Engineer (Field)
Environmental Engineer (Office)
Epidemiologists
Equipment Repair (Not Appliances)
Estimator
Event Planners (no manual duties)
Executive (100K+, under 20% travel)
Executive (50K+, under 20% travel)
Executive (75K+, over 20% travel)
Executive Assistant
Explosives Worker
Exterminator
Factory Foreman
Factory Worker
Family Practice Physician
Farm or Ranch Employee
Farm or Ranch Owner
Fashion Designer
Fast Food Owner / Manager
Fast Food Owner / Manager (Cooking)
Fast Food Worker
Film Cutter / Developer
Film Editor
Financial Advisor
Financial Analyst
Financial Consultant (No Commissions)
Financial Planning Counselor (No Commodities)
Fire Alarm Installer / Repair
Fire Arms Inspectors, Repairers, Sales, Dealers
Firefighter
Firewood Cutting / Delivery
Fisherman
Fishing Boat Owner / Operator / Crew
Fixed Income Trader (No Floor Trading)
Flight Attendant
Flight Instructor
Floor Broker (Securities)
Floor Finisher
Floral Managers/Merchant
Florist (floral arrangers)
Florist Clerks
Food Broker (Inside Only)
Food Broker (Outside)
Food Processing Plant Worker
Food Service Manager (Only Supervisory)
Foreman (Construction-No manual Duties)
Foreman (Except Construction - no manual duties)
Foreman (Oil Field)
Forklift Operator
Freight Handler
Funeral Director/Proprietors (No Embalming)
Furniture Designers
Futures Broker / Trader (Not on Floor)
Futures Broker / Trader (On Floor)
Gambling Industry
Garages, Service Stations and Parking Lot Proprietors, Managers
Garbage Collector
Gardener (Year Round / Salaried)
Garment Worker (Skilled)
Gastroenterologist
General Contractor
General Practice Physician
Geneticist
Genetics Physician
Geologist (Field Work)
Geologist (office duties only)
Geophysicists
Geriatrician
Gift Shop Worker (Hotel)
Glazier
Gold / Silversmith
Golf Pro / Manager (Year Round)
Government Worker
Graphic Artist / Designer
Greenhouse Worker
Greenskeeper (We like to golf)
Grip
Grocery Store Clerk / Cashier
Grocery Store Owner
Guard
Guidance Counselor
Gunsmith
Hairdresser
Harbor / Dock Master (Other)
Harbor Master (Large Commercial Port)
Hazardous Waste Worker
Health / Racquet Club Manager
Health Club / Spa / Pool Worker
Heating / AC Installer / Repair
Heavy Equipment Operator
Hematologist
Historian
Home Health Care Worker
Homemaker (Only When Required by State)
Horticulturist
Hospital Administrator
Hospital Orderly
Hospital/Nursing Home Executives
Hospitalist (Physician)
Host / Hostess (1st Class restaurant)
Hotel (First Class) Clerks
Hotel (First Class) Owners/Managers
Hotel (Small Operations) Owners/Managers
Housekeeper / Maid
Illustrator
Immunologists (non-invasive)
Importer/Exporter (office & sales only, no travel)
Importer/Exporter (other)
Industrial Designer (Degreed)
Inhalation Therapist
Inspector
Institutional Salesperson (Securities, call us)
Instructor (Aerobics, martial arts, skating, skiing, etc)
Instructor (Golf / tennis year-round)
Insurance Adjuster (Office only)
Insurance Adjuster (Outside)
Insurance Agent
Interior Decorator / Designer
Intern (Medical)
Internal Medicine
Interpreter / Translator
Investment Advisor
Investment Banker
Janitor
Jewelry Designer
Jewelry Maker / Repairer
Judges
Junk Dealer / Owner / Yard Worker
Kennel Owner / Worker
Kitchen Manager (No cooking)
Kitchen Worker
Lab Technician
Lab Worker (in hospital)
Laborer
Landscaper (Year-round)
Landscaper Architect (Degreed)
Laundry Worker
Law Enforcement Officer
Legal Secretary
Legal Stenographer
Lens Grinder / Polisher
Librarian
Lighting Director
Lighting Technician
Lineman (Overhead wires)
Liquor Store Owner
Lithographer
Loan Manager (Auto dealership)
Loan Officer / Underwriter (On commission)
Loan Officer / Underwriter (Salaried)
Lobbyist
Location Manager
Locksmith
Logging Worker
Longshoreman
Lumber Dealer / Salesman (Not in yard)
Machinist
Maid
Maintenance (Cleaning)
Maintenance Supervisor
Makeup Artist
Manager
Manicurist
Manufacturers Representative
Marina Owner / Manager (No manual duties)
Marina Worker
Marine Biologist (Field duties)
Marine Biologist (Inside)
Marine Surveyor
Market Maker (Securites, trading own account)
Marketing Director
Martial Arts Instructor
Mason
Massage Therapist (Licensed, MD referred)
Masseuse
Matron
Mechanic
Mechanical Engineer
Media Director (Broadcasting / Entertainment, Call us)
Medical Assistant
Medical Student
Medical Technician (Not otherwise classified)
Merchandise Broker (In office)
Merchandise Broker (Out of office)
Metal Worker (Skilled)
Metallurgical Engineer (Not in mine)
Metallurgist
Meteorologist (Not broadcasting)
Meter Readers
Mid-Wife (Licensed / Certified)
Military (Active duty)
Mine Worker
Mobile Home Sales
Model
Mortgage Banker, Broker (Commission)
Mortgage Banker, Broker (Salary)
Music Teacher
Music Teacher Private Lessons
Musical Instrument Craftsman / Repairer
Musician (Full-time, salaried call us)
Musician (Other)
Nanny
Naturopath
Neonatologist
Nephrologist
Neurologist
Neurosurgeon
Newsstand Owner / Worker
Nightclub Owner / Manager / Employee
Nuclear Energy Worker
Nuclear Engineer
Nuclear Medicine Physician
Nurse (LPN)
Nurse (Private Duty any degree)
Nurse (RN)
Nurse Anesthetist (CRNA)
Nurse Practitioner
Nursery (Agriculture, Owner / Manager only)
Nursery / Greenhouse Worker
Nurses Aide
Obstetrician and Gynecologist
Occupational Therapist
Office Manager
Office Staff (Clerical duties, no lifting over 25 lbs.)
Office Temporary Worker
Offshore Worker
Oncologist
Ophthalmologist
Optician (All duties)
Options Broker / Trader (Not on floor)
Options Broker / Trader (On floor)
Optometrist
Oral Surgeon
Orderly
Orthodontist
Orthopedic Surgeon
Osteopath
Otolaryngologist
Packing / Slaughterhouse (Worker / Supervisor)
Pain Management Physicians
Painter (Inside only)
Paper Hanger
Paralegal
Paramedic (Ambulance-no driving)
Paramedic (Trauma center, inside only)
Parking Lot Owner / Manager
Parts (Delivery)
Parts Supervisor in Dealer (over 5 employees in dept)
Parts Supervisor in Dealer (under 5 employees in dept)
Party / Charter Boat (Captain / Crew)
Patent Agent
Pathologist
Pawn Shop Employee (No weapons)
Pawn Shop Owner (No weapons)
Pediatrician
Perfusionist
Perinatologist
Periodontist
Personal Shopper (Salaried)
Petroleum Engineer (Field, not offshore)
Petroleum Engineer (Office only)
Pharmaceutical Detailing
Pharmacist
Pharmacy Technician
Phlebotomist
Photoengraver
Photographer (Commercial, set or studio, call us)
Photographer (Free-lance)
Photographer (Journalism, in field)
Photographer (Journalism, no field work)
Physiatrists (Physical Medicine, Rehabilitation)
Physical Therapist
Physician's Assistant
Physician - Critical Care
Physician - Emergency Medicine
Physician - Family Practice
Physician - General Practice
Physician - Genetics
Physician - Hospitalist
Physician - Nuclear Medicine
Physician - Pain Management
Physician - Preventive Medicine
Physicist
Physiotherapist
Picture Framer
Pilot
Pipefitter
Pipeline Worker
Pit Boss (Gambling Industry)
Pit Brokers (Securities)
Pizza Parlor Owner / Manager (No cooking)
Pizza Parlor Worker
Placement Director
Plasterer
Plastic Surgeon
Plumber
Podiatrist (All Specialties)
Police Officer
Political Economists
Political Scientist
Portfolio Asset Manager
Portfolio Fund Manager
Portfolio Investment Advisor
Portfolio Money Manager
Position Traders (Securities)
Postal Service Employee
Press Agent
Press Operator
Presser
Preventive Medicine Physician
Priest (Clergy)
Principal (Private school)
Print Space Salesman
Printing Broker (Office only)
Printing Press Operator
Printing Supervisor / Foreman
Prison Worker
Private Detective
Private Duty Nurse (Regardless of degree)
Producer (Not free-lance, call us)
Production / Program Manager
Professor (PhD, private school)
Program Assistant
Program Director
Project Manager
Projectionist
Proofreader
Property Manager / Real Estate (Office only)
Property Manager / Real Estate (Outside duties)
Property Manager / Set Manager
Property Worker / Set Builder
Proprietor
Prosthesis Maker
Psychiatrist
Psychologist - Counselors (other)
Psychologist (MSW)
Psychologist (PhD)
Public Relations Agent
Public Relations Agent (Out of office, call us)
Publisher (Office only)
Pulmonologist
Quarry Worker
Rabbi (Clergy)
Rabbi (Supervising food preparation)
Radiologist
Railroad Worker
Real Estate Agent
Real Estate Appraiser
Real Estate Development
Receiving Clerk
Receptionist
Recording Engineer
Recording Technician
Recruiter
Refinery Worker
Repairer of Scientific or Medical Equipment
Repo Person
Reporter in Studio
Reporter on Site (In USA only)
Research Analyst (Securities-Forecaster, call us)
Reservation Clerk
Respiratory Therapist
Restaurant Owner / Manager (over 40 seats)
Restaurant Owner / Manager (under 40 seats)
Retail Sales
Rheumatologist
Roofer
Route Salesperson
Runner / Delivery Person / Messenger
Safe Repairer
Sales
Sales Professional
Sales Vice President
Sandblaster
Sanitation Supervisor or Worker
Sawmill Owner (No labor)
Sawmill Worker
School Nurse (Private school)
Scientist
Scrap Iron / Metal Dealer (Office)
Screen Writer (Free-lance)
Screen Writer (Salaried full-time, call us)
Scuba Instructor
Sculptor
Secretary
Securities
Securities Analyst (Call us)
Security Person
Service Manager Car Dealer (over 5 employees in dept)
Service Manager Car Dealer (under 5 employees in dept)
Service Station Employee
Service Station Owner
Sewage Supervisor / Worker
Sexton (Clergy)
Sheet Metal Worker
Ship / Boat Crew
Ship Inspector (No diving)
Shipping / Receiving Clerk
Shoemaker / Repairer
Shoeshiner
Sign Designer
Sign Painter (In office)
Silk Screener
Silver / Goldsmith
Singer
Skating Instructor
Skiing Instructor
Slaughterhouse Worker
Social Worker (Private Agency only)
Sociologist
Sound Cutter (Special Effects, call us)
Sound Engineer
Space Salesman
Special Education Therapist
Special Effects Person (Sound Cutter, call us)
Speech Therapist
Sports Instructor (Not otherwise listed)
Sprinkler System Installer / Repairer
Stable Owner / Worker
Stage Manager
Stagehand (Call us)
Station Manager
Stationary Engineer
Statistician
Statisticians
Steeplejack
Stenographer
Stock Clerk (Light goods only)
Stockbroker Account Executive (No commodities)
Stockbroker Investment Officer (No commodities)
Stockbroker Registered Rep (No commodities)
Superintendent (Apartment building)
Superintendent (Construction)
Superintendent (Private school)
Surgeon (all specialties)
Surgical Assistant / Technician
Surveyor
Swimming Pool Maintenance
Switchboard Operator
Systems Analyst
Tailor / Seamstress
Talent Agent / Scout
Tanning Parlor Owner
Tax Preparer
Teacher - Music
Teacher / Principal
Teacher- Shop, Trade, & Phys Ed
Telephone Installer
Telephone Solicitor
Televangelist
Tennis Pro (Year Round)
Textile Worker
Thoracic Surgeon
Ticket Agent (If Entertainment Call Us)
Tile Setter
Timber Cruiser
Title Searcher
Toolmaker
Topographer
Tour Director / Guide
Traders (Securities)
Traffic Manager
Trainer (Other)
Trainer (Team, Certified, College Degree)
Transcriptionist
Translators
Transmitter Engineer (Broadcasting Call Us)
Transportation Broker
Travel Agent
Tree Sprayer
Tree Surgeon
Truck driver
Tunnell Worker
Typesetter (Computer Only)
Typesetter (Manual)
Typist
Typographer
Ultrasound Technician
Underwriter
Union Organizer
Unskilled Worker
Upholsterer
Urban Planner
Urologist
Valet
Vending Machine Service Person
Venture Capitalist
Veterinarian (Large Animal)
Veterinarian (Small Animal)
Vice President of Sales
Visiting Nurse
Vocational Therapist
Waiter / Waitress
Wardrobe Attendant (Call Us)
Wardrobe Supervisor (Call Us)
Warehouse Worker
Watchmaker / Repairman
Watchman
Weatherman (Broadcasting Call Us)
Weightlifting Instructor
Welder
Wigmaker
Window Decorator
Window Washer
Winery Manager
Winery Supervisor
Winery Worker (Not Field Work)
Woods Worker
Woodworker
Word Processor
Writer (Free-Lance)
Writer (Salaried-Full Time)
X-Ray Technician
Yacht Sales
Zoo Directors
Zoologist
Annual Income Range:
Unknown
$1 - $19,999
$20,000 - $49,999
$50,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 - $249,999
$250,000 - $299,999
$300,000 - $349,999
$350,000 - $399,999
$400,000 - $449,999
$450,000 - $499,999
$500,000 +
Please check any of the following that apply to you:
I am receiving disability payments or government assistance such as food stamps, WIC or Medicaid
In the last 5 years, I had bad credit issues, overdue loans, bankruptcy, judgements, tax liens, collections or a debt repayment plan established
I am not a U.S. Citizen
I intend to travel to any country rated 3 or 4 on the
U.S. State Department's Travel Advisory list
I participate in hazardous activities or occupations such as aviation, racing, scuba diving, skydiving, rock climbing, etc.
I have a criminal conviction history or law enforcement infractions
Within the last 5 years, I have received 3 or more moving violations or been convicted of driving while under the influence (DUI)
I have been rated up or declined for life insurance in the past
I have one or more parents or siblings who, prior to age 60, have been diagnosed with or died from cardiovascular, heart or coronary artery disease, stroke or cancer
I now have medical tests or procedures recommended that are not yet completed
I have taken any prescription medications (including from a dentist) in the past 3 years or been diagnosed with any medical condition in the last 10 years
Are you now receiving disability payments from any source?
Yes
No
Check all that apply:
VA
SSDI
Other Govt.
Private Insurance
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?
Yes
No
Check all that apply:
Food Stamps
WIC
Medicaid
Other
Please explain:
Have you had a bankruptcy discharged or established a bankruptcy repayment plan in the last 12 months?
Yes
No
What type of immigrant visa do you have?
Select visa type...
Green Card/Permanent Resident
E
F
H
I
K
L
O
P
V
TN
TD
Other
None
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:
Commercial Aviation
Mountaineering/Rock Climbing
Private Aviation
Scuba Diving
Motorized Racing
Other
Aviation Questionnaire
Do you fly as a pilot or crew member?
Select one...
Pilot
Crew Member
Both Pilot and Crew Member
Total number of hours flown as a pilot
Do you have a valid FAA Medical Certificate?
Yes
No
Class of FAA Medical certificate held
Select one...
First-Class (airline transport pilot)
Second-Class (commercial pilots)
Third-Class (student and recreational pilot)
Date of last FAA medical exam
Was the medical certificate issued under special issuance or with any restrictions?
Yes
No
Special issuance or restriction?
Special Issuance
Restriction
For what condition?
Do you have a valid FAA Airman Certificate?
Yes
No
What type:
Student
Sport
Recreational
Private
Commercial
Airline Transport
What class:
Airplane
Rotorcraft
Powered Lift
Glider
Lighter Than Air
Other
What rating:
Single Engine
Multi-Engine
Land
Sea
Instrument
Other
Do you have an Instrument Flight Rating?
Yes
No
Have you ever been in an aircraft accident, grounded, fined, reprimanded or had your license revoked?
Yes
No
Please Explain:
Date license was obtained:
What is the make and model of the primary aircraft that you currently fly?
Make
Model
Are you a member of any branch of the military (including Reserves or National Guard)?
Yes
No
Branch of Service:
Last Flight in Service:
Type of aircraft in service:
How long have you flown this type of aircraft?
Ever fly into war zones?
Yes
No
Where?
Do you ever fly from an aircraft carrier?
Yes
No
Where?
Is all aviation activity conducted in the United States or Canada?
Yes
No
Please Explain:
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
Hours expected over next 12 months:
List another type of flying as a pilot?
Yes
No
Type of flying as a pilot
Select one...
Scheduled passenger airline
Employer-owned aircraft
Non-scheduled airliner, charter
Pleasure
Personal business transportation
Freight Transportation
Instructor
Instruction as student
Active duty military
National Guard or Reserve
Crop dusting, seeding, aerial spraying
Exhibition or stunt flying
Test or Experimental
Other
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?
Make
Model
Flight time as crew member in hours:
Total to date
Last 12 mos.
Next 12 mos.
Scuba Diving Questions
Do you expect to make more than 10 dives in the next 12 months?
Yes
No
What is the maximum depth to which you will dive?
Select...
Up to 30 ft.
Up to 50 ft.
Up to 75 ft.
Up to 100 ft.
Up to 125 ft.
Up to 130 ft.
Over 130 ft.
Are you a certified dive instructor or professional diver?
Yes
No
Do you participate in any technical or high risk dives, including but not limited to cave, ice, or salvage diving?
Yes
No
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?
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
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?
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
Please provide details of the conviction or infraction (charge(s), state, time served, etc.).
In what year was the most recent moving violation?
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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?
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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?
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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?
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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)?
Select...
Declined
Rated Up
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?
Yes
No
Please check the applicable family member(s) and incidence(s):
• Cardiovascular diagnosis before age 60
Mother
Father
Sibling
• Cardiovascular death before age 60
Mother
Father
Sibling
Has there been any incidence of cancer, other than basal or squamous cell skin cancer, in any parent or sibling prior to age 60?
Yes
No
If you have multiple family members to list, start with any parent.
Which family member?
Select one...
Father
Mother
Brother
Sister
What was the type of cancer?
Select one...
Melanoma, Colon or Lung
Gender-specific (e.g. prostate, ovarian, etc.)
Other
Did this family member pass away from the cancer?
Yes
No
List another familial cancer incidence?
Yes
No
Second Familial Cancer Incidence
Which family member?
Select one...
Father
Mother
Brother
Sister
What was the type of cancer?
Select one...
Melanoma, Colon or Lung
Gender-specific (e.g. prostate, ovarian, etc.)
Other
Did this family member pass away from the cancer?
Yes
No
List another familial cancer incidence?
Yes
No
Third Familial Cancer Incidence
Which family member?
Select one...
Father
Mother
Brother
Sister
What was the type of cancer?
Select one...
Melanoma, Colon or Lung
Gender-specific (e.g. prostate, ovarian, etc.)
Other
Did this family member pass away from the cancer?
Yes
No
List another familial cancer incidence?
Yes
No
Fourth Familial Cancer Incidence
Which family member?
Select one...
Father
Mother
Brother
Sister
What was the type of cancer?
Select one...
Melanoma, Colon or Lung
Gender-specific (e.g. prostate, ovarian, etc.)
Other
Did this family member pass away from the cancer?
Yes
No
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.
Yes
In the past 10 years, have you had or been treated for any of the following conditions?
Alcohol Abuse
Anxiety, ADD or ADHD
Asthma
Blood Pressure (Hypertension)
Cholesterol (Elevated)
Drug Abuse or Addiction
Gastric/Peptic Ulcers
Recurrent Kidney Stones
Do you recall your last blood pressure reading?
Systolic
I Don't Know
130 or less
131 - 135
136 - 140
141 - 145
146 - 150
151 - 155
156 - 160
161 - 170
171 - 180
181 - 190
191 - 200
Over 200
Diastolic
I Don't Know
80 or less
81 - 85
86 - 90
91 - 95
96 - 100
101 - 105
106 - 110
Over 110
Do you recall your last total cholesterol reading and cholesterol HDL ratio?
Total
I Don't Know
200 or less
201 - 210
211 - 215
216 - 220
221 - 225
226 - 230
231 - 240
241 - 250
251 - 260
261 - 265
266 - 270
271 - 275
276 - 280
281 - 285
286 - 290
291 - 300
301 - 310
311 - 320
321 - 325
326 - 330
331 - 340
341 - 350
351 - 399
400 - 450
Over 450
Ratio
I Don't Know
3.5 or less
3.6 to 4.0
4.1 to 4.5
4.6 to 5.0
5.1 to 5.5
5.6 to 6.0
6.1 to 6.5
6.6 to 7.0
7.1 to 8.0
8.1 to 9.0
Over 9.0
Alcohol Abuse Questionnaire
Date of first diagnosis:
How long did the abuse continue?
Were there any relapses from sobriety/abstinence?
No
Yes
Date:
Is there any current alcohol usage?
No
Yes
Frequency and amount:
Date of last alcohol consumption:
Were there any legal problems (such as DUI or other)?
No
Yes
Date:
Ever had any of the following occurrences or symptoms?
Elevated Liver Enzymes
Positive Alcohol Marker
If elevated liver enzymes, are current enzyme levels normal?
No
Yes
Blackouts
Withdrawal Seizures
Alcohol Related Medical Complications
Family/Friends Concern Over Drinking Habits
Alcohol Related Medical Complications date and details:
Use Of Other Substances Such as Marijuana Or Cocaine
Other substances abused details:
Have there been any hospitalizations for this condition?
No
Yes
Dates and details:
Do you currently participate in a group such as Alcoholics Anonymous?
No
Yes
Has therapy been done for this condition?
No
Yes
Details:
Are any medications being taken for this condition?
No
Yes
Details:
Describe how well this condition is under control or if it restricts normal life in any way:
Asthma Questionnaire
Date when first diagnosed:
Age when first diagnosed:
Describe frequency and symptoms:
Is there a trigger for attacks (e.g stress, allergies, exercise, etc.)?
No
Yes
Details:
Are there any episodes within 5 years requiring ER visits or hospitalization?
No
Yes
Details:
Has there been time lost at work or school due to this condition?
No
Yes
Details:
Have you ever smoked?
No
Yes
Date of last tobacco usage:
Including inhalers, are any medications being taken for this condition?
No
Yes
Name of medication and frequency of use:
Have pulmonary function or other tests been done?
No
Yes
Type of tests and results:
Do you have any abnormalities on an ECG or x-ray?
No
Yes
Details:
Describe how well this condition is under control or if it restricts normal life in any way:
Drug Abuse Questionnaire
Date of first diagnosis:
What types of drug(s) were used?
How often were the drugs used?
In what amount were the drugs used?
How long did the abuse last?
When was the date of last use?
Is there any history of drug overdose?
No
Yes
Please list date(s):
Were there any relapses from sobriety/abstinence?
No
Yes
Please list date(s):
Were there any legal problems (such as DUI or other)?
No
Yes
Please give details including dates:
Have there been physical complications or additional psychiatric problems?
No
Yes
Please give details:
Please list current medications:
Is there any current use of alcohol?
No
Yes
Amount and frequency:
Was there participation in a drug rehabilitation program(s)?
No
Yes
Date and name of program:
How long did the program last?
In-Patient
Out-Patient
Has there been or Is there any participation in recovery groups(such as Narcotics Anonymous)?
No
Yes
Are you currently working part-time?
No
Yes
Are you currently working full-time?
No
Yes
Are you currently married?
No
Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Gastric/Peptic Ulcers Questionnaire
Date when first diagnosed:
Please note how the ulcer was treated:
Medications only
Details:
Surgery only
Date and type of surgery:
Was repeat surgery required?
Both
Medications details:
Date and type of surgery:
Was repeat surgery required?
Have there been any recurrences or more than one episode?
No
Yes
How many episodes?
Date, duration, and severity of attack:
Are you on any medications?
No
Yes
Details:
Describe how well this condition is under control or if it restricts normal life in any way:
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
Details:
Has any special testing been done, such as kidney function tests?
No
Yes
Details:
Test results:
Please list the type of treatment received:
Describe how well this condition is under control or if it restricts normal life in any way:
For what medical conditions have you EVER been diagnosed, treated or prescribed any medication?
Alzheimer's
Artery (Coronary) Disease
Arthritis (Psoriatic or Rheumatoid)
What type of Arthritis?
Psoriatic Arthritis
Rheumatoid Arthritis
Cancer
Colitis or Ileitis
COPD
What type of cancer?
Breast Cancer
Leukemia
Melanoma
Prostate Cancer
Skin Cancer
Other
Crohn's Disease
Depression or Mental Illness
Diabetes
Emphysema
Epilepsy
Fibromyalgia
Gout
Heart Disease or Abnormal EKG
Hepatitis or Liver Disease
HIV
Hypothyroidism (low thyroid)
Kidney Disease
Lupus
Mitral Valve Prolapse
Multiple Sclerosis
Pain (Chronic & Ongoing)
Parkinson's Disease
Prostate Issues (no cancer)
Sarcoidosis
Sleep Apnea
Stroke
Vascular Disease
Psoriatic or Rheumatoid Arthritis Questionnaire
Date of first diagnosis:
Age at diagnosis:
Have you ever had any of the following occurrences or symptoms?
Weight Loss
Fever
Low Blood Counts
Heart Disease
Lung Disease
Liver Enzyme Abnormality
Kidney Disease
Other:
Which joints are involved?
Describe present symptoms:
List medications for this condition:
Have you ever taken steroids, gold, or immunosuppresive therapy?
No
Yes
Type and date range:
Please check functional ability:
Fully Active
Sedentary
Uses Walker, Cane, etc.
Uses Wheelchair
Describe how well this condition is under control or if it restricts normal life in any way:
Vascular / Heart Disease or Abnormal EKG Questionnaire
List history of vascular or heart disease (i.e. what diagnosis?)
Date of first diagnosis:
What was your age when diagnosed with this condition?
Ever had any of the following occurrences or symptoms?
Chest Pain
Trouble Breathing
Heart Failure
Heart Palpitations
Atrial Fibrillation/Flutter
Abnormal EKG
Enlarged Heart
Have you ever smoked?
No
Yes
Date of last tobacco usage:
Have any of the following tests been done or recommended?
Echocardiogram
Were there any ST or T wave changes?
No
Yes
Exercise Treadmill or Thallium
Date:
Stress Test
Date:
Results:
Other
Details:
Ever had any of the following procedures done or recommended?
Cardiac Catheterization
How many?
Date:
Coronary Angioplasty
How many?
Date:
Coronary Artery Bypass Graft
How many?
Date:
Coronary Defibrillator
Date:
Coronary Stent
How many?
Date:
Coronary Pacemaker
Date:
Valve Surgery
Which valve?
changes
Are you taking medications for the condition (including aspirin)?
No
Yes
Details:
Medication Selector:
Select One . . .
Albuterol
Aspirin
Elequis
Lipitor
Plavix
Warfarin
Xarelto
Zocor
Are there any restrictions on daily activities?
No
Yes
Details:
What is date and result of last checkup with any heart specialist for this condition?
Note: Underwriters typically require current (within last 24 months) cardiac follow-up on your part and compliance with your doctor's recommendations given that cardiac-related death is #1 cause of death in the U.S. All cardiac and cardiac-related medical records are looked at very closely by the life underwriter and compliance with your doctor's instructions and regular checkups are critical to getting a good life insurance offer.
Are you in compliance with your doctor's recommendations?
No
Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Breast Cancer Questionnaire
Date of diagnosis:
How was the cancer treated?
Removal of tumor only
Date completed:
Lumpectomy or wide excision
Date completed:
Mastectomy
Date completed:
Radiation therapy
Date completed:
Chemotherapy
Date completed:
Hormone therapy
Date completed:
What was the stage of the cancer?
Select one...
Stage 0 (in-situ)
Stage 1
Stage 2
Stage 3
Stage 4
What was the size of the tumor?
Were lymph nodes involved?
No
Yes
How many?
List all medications being taken now for this condition:
Any evidence of recurrence since treatment completed?
No
Yes
Please provide details:
Date cancer was declared "in remission":
Date and results of last mammogram:
Describe how well this condition is under control or if it restricts normal life in any way:
Leukemia Questionnaire
Please select type of leukemia:
Chronic Lymphocytic Leukemia
Hairy Cell Leukemia
Date of diagnosis:
Please note current stage of the leukemia:
Stage 0
Stage I
Stage II
Stage III
Stage IV
Are you on any medications?
No
Yes
Please provide details:
Have any of the following tests been done? If so, please give date and results:
Date of test:
Hemoglobin:
White blood cell count:
Platelet count:
Describe how well this condition is under control or if it restricts normal life in any way:
Date of diagnosis:
Please note type of treatment (check all that apply):
Close observation only
Pentostatin
Splenectomy
Bone marrow transplant
Interferon
2-cdA
Other
Are you on any medications?
No
Yes
Please provide details:
Please provide the results of your most recent CBC (complete blood count):
Date of test:
Hemoglobin:
White blood cell count:
Platelet count:
Has there been any evidence of recurrence?
No
Yes
Please provide details:
Describe how well this condition is under control or if it restricts normal life in any way:
Melanoma Questionnaire
Date of diagnosis:
Please note where the melanoma was located:
Which type of melanoma were you diagnosed with?
Superficial Spreading Melanoma
Nodular Melanoma
Lentigo Maligna Melanoma
Acral Lentiginous Melanoma
Other:
For malignant melanoma only. Please provide all items:
Stage (if available)
Ulcerated?
No
Yes
Clark's Level
Thickness in mm
Any positive Lymph Node?
No
Yes
Details:
Has the cancer metastasized (spread) beyond the skin?
No
Yes
Please provide details:
Has there been any evidence of recurrence?
No
Yes
Please provide details:
List all medications being taken (include inhalers):
Describe how well this condition is under control or if it restricts normal life in any way:
Prostate Cancer Questionnaire
Date of biopsy:
Month
Select
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
How was the cancer treated?
Observation only
TURP (Transurethral Prostatectomy)
Radical Prostatectomy
Radiation Therapy (Seed implant or external beam radiation)
Date radical prostatectomy completed:
Month
Select
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Hormone therapy
Other:
Date treatment completed:
List medications being taken now for any condition:
What stage was the cancer?
What was the Gleason score (scale of 1-10)?
When was the most recent PSA test?
What was the result of the most recent PSA test?
Less than 1
1 or higher
Please provide the most recent PSA level:
What was the PSA prior to treatment?
Has there been any evidence of recurrence?
No
Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Skin Cancer Questionnaire
Date of diagnosis:
What type of skin cancer was diagnosed?
Basal cell carcinoma
Squamous cell carcinoma
Please note where the skin cancer was located:
Has the cancer metastasized (spread) beyond the skin?
No
Yes
Please provide details:
Has there been any evidence of recurrence?
No
Yes
Please provide details:
Are you on any medications?
No
Yes
Please provide details:
Describe how well this condition is under control or if it restricts normal life in any way:
Cancer Questionnaire
Tissue of origin and type of cancer diagnosis (e.g. colon, liver, etc.)
Date of first diagnosis:
Grade, stage, and/or tumor size:
Did the cancer metastasize?
No
Yes
To where did it spread?
How was the cancer treated?
Observation only
Date completed:
Surgery
Date completed:
Chemotherapy
Date completed:
Radiation therapy
Date completed:
Hormone therapy
Date completed:
Other:
Date completed:
Date cancer was declared "in remission":
Any evidence of recurrence since treatment completed?
No
Yes
Please provide details:
List all medications being taken now for this condition:
Date and results of last doctor visit for this condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Colitis / Ileitis Questionnaire
Date when first diagnosed:
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
Details:
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:
Describe how well this condition is under control or if it restricts normal life in any way:
COPD Questionnaire
Date of diagnosis:
Have you ever had any of the following occurrences or symptoms?
Chronic Bronchitis
Emphysema
Restrictive Lung Disease
Asthma
List all medications being taken (include inhalers):
Have you ever had any abnormalities associated with ECG or x-ray?
No
Yes
Please provide details:
Have pulmonary function tests (a breathing test) ever been done?
No
Yes
Please provide details:
Have you ever been hospitalized for this condition?
No
Yes
Please provide details:
Describe how well this condition is under control or if it restricts normal life in any way:
Crohn's Disease Questionnaire
Date of diagnosis:
Have you ever had any of the following occurrences or symptoms?
Hospitalizations for this disorder
Date(s):
Surgery for this disorder
Date(s):
Colonoscopy
Date(s):
List all medications being taken (prescription and non-prescription):
Describe how well this condition is under control or if it restricts normal life in any way:
Anxiety/ADD/Depression/Mental Illness Questionnaire
Indicate diagnosis:
Anxiety/ADD/ADHD
When was the condition diagnosed?
Are you now taking any medication for this condition?
No
Yes
List the medication(s) and daily dosage:
Popular Medication Selector
Select One . . .
Alprazolam
Amitriptyline
Atenolol
Chlordiazepoxide
Clomipramine
Clonazepam
Cymbalta
Diazepam
Doxepin
Effexor
Gabapentin
Lorazepam
Paxil (Paroxetine)
Propranolol
Trazodone
Wellbutrin
Xanax
Zoloft (Sertraline)
Have you received/Are you receiving disability benefits for this condition?
No
Yes
Have you had accidents at work or while driving?
No
Yes
Details:
Depression
When was the condition diagnosed?
What caused the condition?
Are you now taking any medication for this condition?
No
Yes
List the medication(s) and daily dosage:
Popular Medication Selector
Select One . . .
Alprazolam
Amitriptyline
Atenolol
Chlordiazepoxide
Clomipramine
Clonazepam
Cymbalta
Diazepam
Doxepin
Effexor
Gabapentin
Lorazepam
Paxil (Paroxetine)
Propranolol
Trazodone
Xanax
Zoloft (Sertraline)
Are you seeing/have you seen a therapist for this condition?
No
Yes
List date of last consultation:
NOTE: If applicant is currently taking medication for anxiety, ADD, depression or mental illness, most, if not all, life companies will want to see a doctor visit within last 12 months to prove that patient is compliant and receiving ongoing psychiatric care.
Have you received/Are you receiving disability benefits for this condition?
No
Yes
Have you ever attempted suicide?
No
Yes
Details:
Have you ever been hospitalized for this condition?
No
Yes
Details:
Mental Illness
When was the condition diagnosed?
What is the specific condition (i.e bi-polar disorder, schizophrenia, anorexia, etc.)?
Are you now taking any medication for this condition?
No
Yes
List the medication(s) and daily dosage:
Popular Medication Selector
Select One . . .
Alprazolam
Amitriptyline
Atenolol
Chlordiazepoxide
Clomipramine
Clonazepam
Cymbalta
Diazepam
Doxepin
Effexor
Gabapentin
Lorazepam
Paxil (Paroxetine)
Propranolol
Trazodone
Xanax
Zoloft (Sertraline)
Are you seeing/have you seen a therapist for this condition?
No
Yes
List date of last consultation:
NOTE: If applicant is currently taking medication for anxiety, ADD, depression or mental illness, most, if not all, life companies will want to see a doctor visit within last 12 months to prove that patient is compliant and receiving ongoing psychiatric care.
Have you received/Are you receiving disability benefits for this condition?
No
Yes
Have you ever attempted suicide?
No
Yes
Details:
Have you ever been hospitalized for this condition?
No
Yes
Details:
Do you have a history of substance abuse (alcohol or drug)?
No
Yes
Details:
Have you been hospitalized, required ECT, been seen in the emergency room, or been on disability for psychiatric symptoms or treatment?
No
Yes
Details:
Describe how well this condition is under control or if it restricts normal life in any way:
Diabetes Questionnaire
What type of Diabetes?
Select...
Pre-Diabetes
Gestational
Type 1 (Juvenile)
Type 2 (Adult onset)
Age at diagnosis:
Use a numeric value for the age at diagnosis.
What was your most recent hemoglobin A1c?
Select...
Don't know
Less than 6
6 to 6.4
6.5 to 6.9
7 to 7.4
7.5 to 7.9
8 to 8.9
9 to 9.9
10 to 10.9
11 or higher
What was your most recent blood sugar reading?
Select...
Don't know
Normal (70-100 fasting, 70-140 after meal)
Pre-diabetes (101-125 fasting, 141-200 after meal)
Diabetic (125+ fasting, 200+ after meal)
Do you monitor your own blood sugar?
No
Yes
How often do you visit your physician?
Date you last visited your physician:
The diabetes is controlled by:
Diet alone
Oral medication
Medication and dosage:
Medication Selector:
Select One . . .
Adlyxin
Bydureon
Byetta
Glipizide
Humalog
Januvia
Metformin
Novolog
Ozempic
Trulicity
Victoza
Insulin
Amount of units/day:
Are you on any other medications?
No
Yes
Details:
Please check if you have had any of the following:
Chest Pain or coronary artery disease
Overweight
Protein in the urine
Elevated lipids
Neuropathy
Black out spells
Retinopathy
Hypertension
Abnormal ECG
Describe how well this condition is under control or if it restricts normal life in any way:
Emphysema Questionnaire
Date of diagnosis:
Type of lung disease:
Chronic Bronchitis
Emphysema
Restrictive Lung Disease
Asthma
Have you ever been hospitalized for this condition?
No
Yes
Please provide details:
Are you on any medications (include inhalers)?
No
Yes
Please provide details:
Have pulmonary function tests (a breathing test) ever been done?
No
Yes
Please provide most recent results and date:
Do you have any abnormalities on an ECG or x-ray?
No
Yes
Please provide details:
Describe how well this condition is under control or if it restricts normal life in any way:
Epilepsy Questionnaire
Please provide date of first episode/diagnosis:
Please provide date of most recent episode:
Please provide number of episodes per year:
Please note type of seizure:
Complex/Partial Seizure
Tonic-Clonic Seizure
Absense Seizure
Myoclonic Seizure
Are you on any medications?
No
Yes
Name of medication(s) amount and frequency:
Have you been hospitalized for treatment of epilepsy?
No
Yes
Please give details:
Describe how well this condition is under control or if it restricts normal life in any way:
Chronic Pain / Fibromyalgia Questionnaire
Date of diagnosis:
Is the pain localized or widespread?
Are you taking any medication?
No
Yes
Which medication(s)? Include dosage:
Do you have any disabilities or physical impairments?
No
Yes
Please provide details:
Do you have a history of mental illness?
No
Yes
Please provide details:
Do you drink alcohol?
No
Yes
How much and how often?
Describe how well this condition is under control or if it restricts normal life in any way:
Gout Questionnaire
Date of diagnosis:
What is the date of your last attack?
How frequent are attacks?
Are you taking any medication?
No
Yes
Please provide details:
Are there joint deformities?
No
Yes
Do you have any physical impairments?
Do you drink alcohol?
No
Yes
What amount and frequency?
Describe how well this condition is under control or if it restricts normal life in any way:
Hepatitis/Liver Disease Questionnaire
Date of diagnosis:
What is the diagnosis?
Hepatitis A
Hepatitis B, resolved
Hepatitis B, carrier or chronic infection
Hepatitis C (non-A/non-B)
Jaundice
Fatty Liver
Cirrhosis
Other:
Have any of the following tests been done?
Liver Enzyme Tests
Date:
AST/SGOT
Result:
ALT/SGPT
Result:
GGPT
Result:
Liver ultrasound
Normal
Abnormal
CT scan/MRI
Normal
Abnormal
Liver Biopsy
Normal
Abnormal
Do you drink alcohol?
No
Yes
What amount and frequency?
What type(s) of treatment have been/are being done?
Observation
Medication
Details:
Surgery
Date:
Have you been treated with interferon or anti-viral drugs?
No
Yes
Please provide details:
Describe how well this condition is under control or if it restricts normal life in any way:
Hypothyroidism Questionnaire
Date when first diagnosed:
Is this condition under control?
Has an ultrasound or radioactive scan of the thyroid been done?
No
Yes
What were the results?
Are you taking any medications?
No
Yes
Medication name, amount and frequency:
Medication Selector:
Select One . . .
Armour Thyroid
Cytomel
Levothroid
Levothyroxine
Levoxyl
Synthroid
Thyroxine
Are your thyroid levels normal?
No
Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Kidney Disease Questionnaire
Please select type:
Glomerulonephritis
Kidney Transplant
Proteinuria
Polycystic Kidney Disease
Date of diagnosis:
Please note type of Glomerulonephritis:
Was a kidney biopsy done?
No
Yes
Please give date and diagnosis:
Are you on any medications?
No
Yes
Please provide details:
Please provide the your most recent readings for:
Blood Pressure
BUN
Creatinine
Urinalysis
Describe how well this condition is under control or if it restricts normal life in any way:
Please list date(s) of transplant(s):
Please check cause of the end stage renal disease which led to the transplant:
Diabetes
Polycystic Kidney Disease
Glomerulonephritis
Ephrosclerosis
Systemic Lupus Erythematosus
Other
What was the source of the donor kidney?
Cadaver
Identical Twin
Living Related Donor
Are you on any medications?
No
Yes
Please provide details:
Please provide the most recent results of the following kidney function tests:
BUN
Serum Creatinine
Urinalysis
Please note if any of the following have occurred (check all that apply):
Frequent Infection
Toxicity From Treatment
Rejection Episodes
Cancer
High Blood Pressure
Disease Recurrence
Cardiovascular Disease
Describe how well this condition is under control or if it restricts normal life in any way:
How long in years has this abnormality been present?
Has a specific cause for the proteinuria been found?
No
Yes
Please provide details:
Please give the date and results of the most recent urinalysis:
Protein
Red Blood Cells (RBC's)
White Blood Cells (WBC's)
Protein/Creatinine Ratio
Please check if you have had any of the following:
Weight Loss
Biliary Cirrhosis
Heart Disease
Liver Enzyme Abnormality
Lung Disease
Kidney Disease
Raynaud's Disease
Trouble Swallowing
If any of the following urinary tests have been completed, please give the date and result:
Microalbumin
24-hour Protein
24-hour Creatinine Clearance
Other
Are you on any medications?
No
Yes
Please provide details:
Describe how well this condition is under control or if it restricts normal life in any way:
Do any other family members have ADPKD?
No
Yes
Please provide details:
Was ADPKD diagnosed by ultrasound?
No
Yes
Please provide the date and results of your most recent urinalysis.
Protein
Red blood cells (RBC)
White blood cells (WBC)
Protein/Creatinine ratio
Please provide the date and results of the most recent kidney function tests.
BUN
Serum Creatinine
Are you currently on any medications?
No
Yes
Please give date and diagnosis:
Describe how well this condition is under control or if it restricts normal life in any way:
Lupus Questionnaire
Date when first diagnosed:
Which type of lupus?
Systemic Lupus Erythematosus
Discoid Lupus
Drug Induced Lupus
Are you taking any medication for this condition?
No
Yes
Details:
Are you currently receiving any other treatment for this condition?
No
Yes
Details:
Is the lupus active?
No
Yes
How long has it been in remission?
Please check if you have any of the following:
Low blood counts
Lung involvement
Proteinuria
High blood pressure
Neurologic disorder
Heart involvement (pericarditis)
Renal insufficiency or failure
Describe how well this condition is under control or if it restricts normal life in any way:
Mitral Valve Prolapse Questionnaire
Date of diagnosis:
How long has this abnormality been present?
Have you ever had any of the following occurrences or symptoms?
Chest Pain
Palpitations
Trouble Breathing
Dizziness
Is the MVP associated with regurgitation?
No
Yes
Is there a history of any other heart disease in addition to the mitral valve prolapse (problems with other valves, coronary artery disease, etc.)?
No
Yes
Please provide details:
Has an echocardiogram (ultrasound of the heart) been done?
No
Yes
Please provide details:
Is there a murmur?
No
Yes
What is the grade?
List all medications being taken now for any condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Multiple Sclerosis Questionnaire
Date when first diagnosed:
Please indicate the number of episodes and date of last episode:
Are you on any medications?
No
Yes
Details:
Please note current neurologic status and/or symptoms.
normal
minimal residual impairment
moderate residual impairment
severe residual impairment
Please specify:
Please provide all MRI brain scan reports:
Describe how well this condition is under control or if it restricts normal life in any way:
Parkinson's Disease Questionnaire
Date of diagnosis:
Please note the functional stage of you currently:
Stage I
unilateral involvement
Stage II
bilateral involvement but normal stance
Stage III
bilateral involvement with mild postural imbalance but able to lead an independent life
Stage IV
bilateral involvement with postural instability, requires substantial help
Stage V
severe disease; restricted to bed or wheelchair
Has there been any evidence of progression?
No
Yes
Please provide details:
Are you on any medications for this condition?
No
Yes
Please provide details:
Please note if any of the following have occurred (check all that apply):
Dementia
Recurrent Infections
Memory Problems
Falls
Aspiration
Recurrent Injuries
Depression
Describe how well this condition is under control or if it restricts normal life in any way:
Prostate Issues (no cancer)
Date of diagnosis:
Is there a history of abnormal PSA levels?
No
Yes
What are your current PSA levels?
What is the date of your last colonoscopy or biopsy?
What were the results?
Is surgery pending?
No
Yes
Is there a history of any other conditions related to the prostate?
No
Yes
Please provide details:
Are you now taking any medication for this condition?
No
Yes
List the medication(s) and daily dosage:
Describe how well this condition is under control or if it restricts normal life in any way:
Sarcoidosis Questionnaire
Date of diagnosis:
Was a biopsy done?
No
Yes
Please indicate the stage of the sarcoidosis:
0
1
2
3
4
How was the sarcoid treated?
No treatment
Prednisone
Are you on any medications?
No
Yes
Name of medication(s) amount and frequency:
What organs were involved?
Lung
Heart
Liver or Spleen
Eyes
Kidney
Central Nervous System
Skin
Lymph Nodes
Have you had any recent pulmonary function tests done?
No
Yes
Please provide the results:
Has there been any evidence of recurrence or progression?
No
Yes
Please provide details:
Describe how well this condition is under control or if it restricts normal life in any way:
Sleep Apnea Questionnaire
Please list date when first diagnosed:
Has a sleep study been recommended?
No
Yes
Was it completed?
No
Yes
Date completed:
Why has it not been completed?
Was the sleep apnea diagnosed as:
Obstructive
Central
Unknown
How is the sleep apnea being treated?
Observation alone
Weight loss
C PAP/BiPAP mask
Surgery
Other
Details:
Are you on any medications?
No
Yes
Name of medication(s) amount and frequency:
What was your last AHI (apnea-hypopnea index) reading?
OR
I don't know
What was your last O2 (Oxygen) Saturation Level reading?
OR
I don't know
Please check if you have had any of the following:
Lung disease
Accidents such as motor vehicle accidents
Heart disease
Arrhythmia
Stroke
Depression
Hypertension
Sarcoidosis
Describe how well this condition is under control or if it restricts normal life in any way:
Stroke Questionnaire
Please indicate date(s) of episodes(s):
Do you have any current neurological residuals?
No
Yes
Please provide details:
Have you ever had any of the following occurrences or symptoms?
High Blood Pressure
High Cholesterol
Coronary Artery Disease
Atrial Fibrillation
Diabetes
Peripheral Vascular Disease
Heart Murmur
Carotid Disease
Describe how well this condition is under control or if it restricts normal life in any way:
Do you have any health conditions or non-medical situations that have not already been disclosed?
Yes
No
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 $50,000.
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