• Do any of these apply?
  • Health
  • Personal

Do any of these apply?

How much coverage do you need?

What type of coverage are you seeking?

Do you have plans to engage in any of the following activities within the next two years?

Do you have plans to travel, live, or work outside the US within the next two years?

Have you used any form of nicotine or tobacco in the last three years?

Have you used marijuana in the last 12 months?

In the last ten years, have you used cocaine, hallucinogens, or other controlled substances (not prescribed by a physician)?

In the last five years, have you been convicted of a misdemeanor or felony, have you served in a probationary or parole program, or do you have any criminal charges pending?

How tall are you?

How many pounds do you weigh?


Has you weight changed by more than ten pounds in the last year?


In the last 10 years, have you been diagnosed, treated, hospitalized, or prescribed medication by a medical professional for any of the following?

Have you been a patient in any medical facility in the last 5 years?

In the last 5 years, has a physician recommended any test (other than HIV) or treatment that you have not yet completed, or are you waiting to receive results for any tests now?

Have you ever had an organ transplant?

Have you been diagnosed by a physician with AIDS or ARC?


Do you have a regular physician?

doctor's last name or name of medical facility

street address



zip code

phone number

date of last medical doctor's visit


Has a biological parent or sibling been diagnosed by a member of the medical profession with diabetes, cancer, or heart disease prior to the age of 60?


Where were you born?

Are you a U.S. Citizen or lawful permanent resident who has lived in the U.S. for more than 2 years?

Do you currently have life insurance or an annuity, not including life insurance through an employer?

Have you applied for any other life insurance, a reinstatement, or a renewal in the last 5 years?

Are you currently employed?

What is your occupation?

What is your annual income?

What is your annual household income?

Secondary Addressee Let us know whom to contact regarding your payment, in case we can't reach you at your current address. Would you like to add a secondary addressee?

Do you have a valid driver's license?

If so, what is the driver's license or state ID number? Provide the abbreviation of your state as well.

In the last 10 years, has your driver's license been suspended or revoked or have you been convicted of driving under the influence?

In the last 5 years, how many moving violations or convictions have you had?

What is your address?

What is your email address?

What is your phone number?

When is your birthday?

What is your sex?

What is your social security number?

What is your name?