Questionnaire

Fill out the questionnaire for more accurate quotes

    Health

    Gender

    Height

    Have you used any tobacco, nicotine or marijuana products in the last 5 years?

    Have you ever been diagnosed or received treatment for Lung Disease? COPD, Emphysema or Asthma?

    Do you require the use of any oxygen or inhalers?

    Have you ever been diagnosed or received treatment for diabetes?

    Have you ever been diagnosed with Cancer?

    Have you ever had any kidney insufficiency? Dialysis? Cirrhosis? Hepatitis?

    Have you ever had a Heart Attack, Bypass Surgery, Stent Surgery, Angina, Pacemaker, Defibrillator, Stroke, Seizure, Aneurism?

    Congestive Heart Failure?

    Lupus? Multiple Sclerosis? Parkinson’s? Lou Gehrig’s?

    Have you ever been diagnosed or received treatment for Depression, Bipolar Disorder, Schizophrenia, Alzheimer’s or Dementia?

    Medications

    Financial

    Do you have any active burial or life insurance inforce?

    Do you currently receive Social Security or Disability payments from the government?

    Do you have an active checking or savings account?

    Is anyone other than you paying for this policy?