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Coverage Amount
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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. Click here to access the Life Happens life insurance needs calculator which can guide you through choosing an amount.
    
  
ZIP Code
  
Birth Date (Ages 14 Days - 85 Years)
Gender
Any tobacco, nicotine, marijuana, vape or tobacco substitute use?
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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.
Height
 feet    inches
Weight (with clothes on)
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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.
Are you now receiving disability payments or government assistance such as food stamps, WIC or Medicaid?
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Why do life insurance companies ask about this?
Financial justification and the ability of the policyholder to pay premiums are important considerations the insurance company will make when underwriting an application. If you receive disability income payments or government aid of any kind, it does not mean you will not qualify for coverage. However, it may impact your eligibility for some policies or the amount of coverage you can qualify for. By answering truthfully here we will be able to show you the policies for which you will most likely be approved.
Are you now receiving disability payments from any source?
Check all that apply:
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?
Check all that apply:
Please explain:
Do you work at a paying job (employed or self-employed) at least 30 hours per week?
Occupation:
Annual Income Range:
Do you have any bankruptcy history?
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Why do life insurance companies ask about this?
Financial justification is an important evaluation made by any insurance company reviewing an application for coverage. Having a personal bankruptcy history does not mean you will not qualify for coverage, but the recency of it may affect which plans are available to you. The good news is that when you apply for life insurance, any credit bureau inquiry the insurance company might make will have no impact on your credit score.
Has it been less than 2 years since the bankruptcy has been discharged or are you currently in a repayment plan?
Are you a U.S. Citizen?
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Why do life insurance companies ask about citizenship status?
U.S. citizenship is not required to qualify for most types of life insurance. If you are not a U.S. citizen, your residency status will be important in determining which policies may be available to you. We ask you to provide your residency status or visa type along with details including your country of citizenship, date of entry into the U.S. and long-term residency plans so we can find the best plan for you.
What type of visa do you have?
Do you intend to travel to any country rated higher than Level 2 on
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Why do life insurers ask about this?
Intended foreign travel to dangerous countries at the time you buy life insurance is looked at very carefully by all US life insurers. The key word is "intention". If you currently have no intention of traveling to any country rated higher than level 2, then OK to answer "No". If your answer is "Yes" and you don't see a price that you like, then give us a call to discuss your situation. We can guide you.
Please specify the purpose of travel, location to be visited, and number of days expected in coming year.
Do you participate in hazardous activities or occupations (aviation, racing, scuba diving, skydiving, rock climbing, etc.)?
Check all that apply:
Aviation Questionnaire
Do you fly as a pilot or crew member?
Total number of hours flown as a pilot
Do you have a valid FAA Medical Certificate?
Do you have a valid FAA Airman Certificate?
Do you have an Instrument Flight Rating?
Have you ever been in an aircraft accident, grounded, fined, reprimanded or had your license revoked?
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)?
Is all aviation activity conducted in the United States or Canada?
Type of flying as a pilot
Hours expected over next 12 months:
List another type of flying 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?
What is the maximum depth to which you will dive?
Are you a certified dive instructor or professional diver?
Do you participate in any technical or high risk dives, including but not limited to cave, ice, or salvage diving?
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.
Do you have any criminal conviction history or law enforcement infractions?
In what year was the conviction or infraction?
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?
Please provide details of the conviction or infraction (charge(s), state, time served, etc.).
Within the last 5 years, have you received 3 or more moving violations or been convicted of driving while under the influence (DUI)?
In what year was the infraction?
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?
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?
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?
Please provide details of the conviction or infraction (charge(s), state, time served, etc.).
Have you previously applied for life insurance and had the premium increased or declined?
What was the name of the insurance company?
What was the approximate date of your application?
Were you declined or rated up (approved for a higher premium than you applied for)?
What was the reason given for the decline or rate-up?
Do you have any parents or siblings who, prior to age 60, have been diagnosed with or died from cardiovascular, heart or coronary artery disease, stroke or cancer?
Has there been any incidence of cardiovascular, heart or coronary artery disease, or stroke in any parent or sibling prior to age 60?
Please check the applicable family member(s) and incidence(s):
• Cardiovascular diagnosis before age 60
• Cardiovascular death before age 60
Has there been any incidence of cancer, other than basal or squamous cell skin cancer, in any parent or sibling prior to age 60?
Have any medical tests or procedures been ordered or recommended that you have not yet completed?
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.
Have you been diagnosed with any medical conditions in the last 10 years or taken any prescription medications (including from a dentist) in the past 3 years?
In the past 10 years, have you had or been treated for any of the following conditions?
For what medical conditions have you EVER been diagnosed, treated or prescribed any medication?
Do you have any health conditions or non-medical situations that have not already been disclosed?
What was the medical condition?
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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