Stroke/TIA Life Insurance Quote Request

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Since 1969 We have helped thousands of TIA and stroke victims get the best rate possible.

We will do the exact same thing for you!

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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.

Coverage Amount* This field is required.

Insurance Type* This field is required.

Term Length

Height* This field is required.

Weight (in pounds)* This field is required.

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

How Long Since You Quit Tobacco/Nicotine ?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.

What Tobacco/Nicotine Do You Use?

Do You Take Any Medications or Aspirin?* 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.

Which have you had?* This field is required.

Stroke

TIA

Both

Date or Dates of your Stroke/TIA?* This field is required.

For Stroke Only, was it:

Ischemic (caused by blockage)

Hemorrhagic (caused by rupture)

Unknown

Any Residual Affects or Debilitation Because of Stroke/TIA? check all that apply

Memory Loss

Speech Impediment

Vision Problems

Depth Perception

Bladder/Bowel Control

Trouble Thinking/Reasoning

Paralysis

Trouble Walking

Severe Headaches

Have you ever been diagnosed with or treated for any of the following:

Heart Issues, Heart Disease, Heart Attacks, etc.

Cancers, Tumors, Melanoma or other Malignancies?

Depression, Anxiety, Bipolar, Mental or Nervous Disorders?

Colitis, Hepatitis, Disorders of Liver, Intestines or Stomach?

Other Medical Issue

Exact diagnosis, approx date diagnosed, treatment, prognosis?

Other Info/Details You'd Like to Provide:

Name* This field is required.

First Name

Last Name

E-mail* This field is required.

Date Received

Date

Hour

Minutes