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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.		State:
Birth Date (Ages 18-85):			Quote a child, 14 days to 14 years old
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.

Complete all fields below so that we can now refine your quote
to your own health history. This ensures lowest possible pricing.

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 bought a term life insurance policy in the last 60 months?
(If yes, we'll show you some brand new no-exam plans)

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 Life-Long-Term Care Combo Plans

Now Quoting Instant-Decision (no waiting) Plans

America's top life insurance companies

Instant Life Insurance Quotes

Compare rates of 30 leading Life Insurance companies in seconds

Compare rates of 30 leading Life
Insurance companies in seconds