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Coverage Amount Close How much coverage do I need? If you are a family breadwinner with dependents, financial planners suggest carrying ten times your annual income. If you are a non-working caregiver at home, we suggest your choice of $150,000 to $500,000. If you are looking for burial coverage only, we suggest $5,000 to $25,000. Click here to access the Life Happens life insurance needs calculator.	Needs Calculator
State of Residence
Birth Date (Ages 14 Days - 85 Years)
Sex	Male Female
Any tobacco, nicotine or marijuana use? Close 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.
Height & Weight	Height Weight (with clothes on) 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.

Non-medical questions that can affect your premium

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

Have you ever filed for bankruptcy?

No Yes

Are you a U.S. Citizen?

No Yes

Do you intend to participate in commercial aviation, private aviation, scuba diving, motorized racing, mountaineering or rock climbing, travel to any country on the U.S. State Department's Travel Warnings list, or any other potentially hazardous activities?

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?

No Yes

Have you ever had any other criminal convictions, law enforcement
infractions of any kind or been on parole or probation?

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?

Do you recall what your last cholesterol ratio was?

Are you taking cholesterol medication?

No 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

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 for this condition?

No Yes

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
Type of tests:
Test results:
Please list the type of treatment received:

For what medical conditions have you EVER been diagnosed, treated or prescribed any medication?

Prostate Cancer Questionnaire

Date of biopsy:

Month Year

How was the cancer treated?

Observation only

TURP (Transurethral Prostatectomy)

Radical Prostatectomy

Radiation Therapy (Seed implant or external beam radiation)

Hormone therapy

Other :

Date treatment completed:

List all medications being taken now for this condition:

What stage was the cancer?

What was the Gleason score?

When was the most recent PSA test?

What was the result of the most recent PSA test?

Less than 1 1 or higher

What was the PSA prior to treatment?

Has there been any evidence of recurrence?

No Yes

Cancer Questionnaire

List tissue of origin and kind of cancer diagnosis you have (i.e. colon, ovarian, liver, etc.)

Date of first diagnosis:

Grade, stage, and/or tumor size:

Did the cancer metastasize?	No Yes
Where to?

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
Details:

List all medications being taken now for this condition:

Date and results of last doctor visit for this condition:

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 for this condition?

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:

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 for this condition?

No Yes

Have you been hospitalized for treatment of epilepsy?

No Yes

Chronic Pain / 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?

Do you have any health conditions or non-medical situations that have not already been disclosed?

No Yes

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1-800-324-6370

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7 a.m. - 8 p.m.

Central Time (CT)

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