Critical/Chronic Insurance Quote Request

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Since 1969 We have helped thousands of people get the best rate possible, including the best life insurance with chronic, critical and even long term care insurance built in to the policy.

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State of Residence* This field is required.

Gender* This field is required.

Female

Male

Date of Birth* This field is required.

Quote Only Products with Critical/Chronic Benefits * This field is required.

Coverage Amount* This field is required.

Insurance Type* This field is required.

Term Length

Do You Currently Have Life Insurance?* This field is required.

Yes

Are You Looking to Replace This Policy?

Yes

Have your parents or siblings had heart disease, cancer or stroke prior to age 60?* This field is required.

Yes

If Yes, please indicate family member, diagnosis, age of diagnosis and/or age at death, or please provide current age if still living

Have you had more than 1 moving violation in past 3 years* This field is required.

yes

How Many Moving Violations

2 in past 3 years

3 in past 3 years

4 in past 3 years

More than 4 in past 3 years

Has Your Drivers License Been Suspended in Past 10 Years?* This field is required.

Yes

Why, When and for How Long Suspended?

Do You Do Any of the Following:

Scuba Diving

Private Pilot

Motorized Racing

Skydiving/Parachuting

Mountain/Rock Climbing

Regular Ballooning

Height* This field is required.

Weight (in pounds)* This field is required.Insurance companies like to see a stable weight for 12 full month's since they know people try to drop weight prior to applying for insurance

Do You Smoke or Use Tobacco or Nicotine in ANY form?* This field is required.

How Long Since You Quit?Did you know that most companies will consider you to be a smoker for 12-24 months after you quit...It is also important to note that the non-smoker rate classes will vary by company and time since you quit.

Do You Take Any Medications?* This field is required.

Yes

Please include medication name, dosage and frequency takenDon't worry if you do not have exact spelling. It's most important from underwriting standpoint to know why you are taking something.

Ever been diagnosed with or treated for any of the following?

Heart Disease

Diabetes

Cancer

Stroke, TIA or Mini Stroke

Depression, Anxiety, Other Mental Health

Kidney Disease

Liver Disease

Sleep Apnea

Alcohol/Substance Abuse

Autoimmune or Autoinflammatory Disorder

Asthma, COPD or other Respiratory Disease

Alzheimer's or Dementia

Currently Disabled

Other Medical Issue in Medical Records

Please Provide Details To Above

Any Other Info You'd Like to Provide That Could Help Us To Get You A Better Offer:

Name* This field is required.

First Name

Last Name

E-mail* This field is required.