Life Insurance Quote Form What is your height?*5' 0"5' 1"5' 2"5' 3"5' 4"5' 5"5' 6"5' 7"5' 8"5' 9"5' 10"5' 11"6'6' 1"6' 2"6' 3"6' 4"6' 5"6' 6"6' 7"6' 8"6' 9"6' 10"6' 11"7'What is your weight?*Have you ever used any type of tobacco, chewing tobacco, nicotine patch/gum or e-cigarettes?* Yes No If yes Currently use Stopped using over 1-year ago Stopped using over 3-years ago Stopped using over 5-years ago Would you consider yourself to have high blood pressure?* Yes No Are you taking a prescription for high blood pressure Yes No Would you consider yourself to have high cholesterol level?* Yes No Are you taking a prescription for high cholesterol? Yes no Are you currently taking a prescription drug for a medical condition?* Yes No Are you planning international travel in the next year?* Yes No Are you engaged in scuba diving, hang gliding, sky diving, racing, pilot airplanes, or like activity?* Yes No Are you currently under doctor care for any type of medical or psychology treatment?* Yes No Have you been to a doctor in the last 5 years years for anything other than routine physical/annual exams or cold/flu like symptoms?* Yes No Have you been admitted, over night to a hospital in the last 10 years for something other than a birth of a child?* Yes No Are both of your parents alive?* Yes No Did a parent die before age 60 of cancer or a heart related condition? Yes No Have you had any speeding tickets in the last 3 years?* Yes No Have you had any DUI, reckless driving or suspensions in the last 5 years?* Yes No Name* First Last Email* Phone*Date of Birth* MM slash DD slash YYYY Sex* Male Female Amount of Coverage* $100,000 $250,000 $500,000 $1,000,000 Term* 10-years 15-years 20-years 30-years
