Almost done! We just need some more information
To make sure we get you the right quote for your final expense insurance, please complete the following information.
It should only take about 5-10 minutes of your time.
Please note, these questions apply to the person being insured.
Email
*
Address
City
State
Postal code
Date of birth
What gender are you?
Male
Female
Other
Are you currently
1. bedridden or confined to any hospital, nursing home, long-term care facility or skilled nursing facility; or receiving or been advised to receive care in a nursing home, hospice care, or home health care?
2. requiring assistance with activities of daily living such as taking medications, bathing, dressing, eating, toileting, getting in and out of a chair or bed, or control of bowel or bladder problems?
3. requiring any of the following (other than for fractures, bone or joint surgery, including replacement): wheelchair, electric scooter, or oxygen equipment to assist breathing (excluding use for sleep apnea)?
4. None of the above
Have any of the following applied to you? (Check all that apply)
diagnosed as having Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or Human Immunodeficiency Virus (HIV) Infection (symptomatic or asymptomatic) or been treated for AIDS, ARC, or HIV by a physician or health care provider?
diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for Alzheimer’s Disease, Dementia, Huntington’s Disease, Sickle Cell Anemia, Myelodysplastic Syndrome (MDS), Lou Gehrig’s Disease (ALS), Quadriplegia, Paraplegia, Down’s Syndrome, mental incapacity, congestive heart failure, Cirrhosis, Metastatic Cancer or recurrent Cancer of the same type?
diagnosed with insulin shock, diabetic coma, or had an amputation due to diabetic complications or diagnosed with End Stage Renal Disease or requiring dialysis?
advised to receive or have received an organ or bone marrow transplant?
diagnosed by a physician or health care provider as having a terminal medical condition that is expected to result in death within the next twelve 12 months?
None of the above
In the past 12 months, have you ever been:
advised by a physician to have a surgical operation, diagnostic testing other than for routine screening purposes or for those related to HIV/AIDS, treatment, hospitalization, or other procedure which has not been done or for which results are not known?
diagnosed by a physician or health care provider as having heart disease or heart surgery of any kind?
None of the above
In the past 2 years, has the Proposed Insured been diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for any form of cancer (except basal or squamous cell skin cancer)?
Yes
No
Have you ever (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for:
Diabetes before age 50 or diabetes at any age with complications of Retinopathy (eye), Nephropathy (kidney), Neuropathy (nerve) or Peripheral Vascular Disease (PVD or PAD)?
Hepatitis C?
Chronic Lung Disease, including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, or Sarcoidosis?
"No" to all
In the past 4 years, have you ever: (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for: (check all that apply)
Cancer, Leukemia, Melanoma or any other internal cancer (except basal or squamous cell skin cancer)?
Chronic Kidney Disease, Systemic Lupus or Scleroderma?
Bipolar Depression, Schizophrenia, Parkinson’s Disease or Multiple Sclerosis?
"No" to all
In the past 2 years, has the Proposed Insured: (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for: (check all that apply)
Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Cardiomyopathy, irregular heart rhythm, or Valvular Heart Disease with surgical repair or replacement?
Stroke or Transient Ischemic Attack (TIA)?
"NO" to all
In the past 2 years, have you ever: (check all that apply)
been convicted of or currently awaiting trial for a felony?
been treated for or advised to have treatment for alcohol or drug abuse or convicted more than once of reckless driving or driving under the influence of drugs or alcohol?
used unlawful drugs in any form or abused or misused prescription drugs?
"NO" to all
In the past 2 years, have you ever been hospitalized by a physician or health care provider for any mental or nervous disorder?
Yes
No
In the past 12 months, have you ever consulted a physician for chronic cough, unexplained weight loss greater than 10 pounds, fatigue or unexplained gastrointestinal bleeding?
Yes
No
How would you like to pay the premium for your new life insurance poliy?
Annually
Semi-Annually
Quarterly
Monthly (Automated Bank Account Withdrawl)
How much death benefit are you requesting ($2,000 - $40,000)
$
How many beneficiaries do you want?
0
1
2
3
4
5+
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List all your beneficiaries, their full names, relationship to you, and their date of birth.
Do you have any pending applications or existing life insurance or annuity contracts with the company or any other company?
Yes
No
Is the insurance applied for intended to replace or change any life insurance or annuity contract in force with the company or any other company?
Yes
No