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To receive a quick quote, fill out the simple form.

First Name *

Last Name *

Date of birth *

Age *

Gender *

Male

Female

Phone *

Address *

Email *

City *

State *

Postal code *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Are you looking for yourself or for a loved one? *

Myself

Loved One

If you answered Loved One, what is your relationship to the Insured?

Do you currently have life insurance? *

Yes, but I’m looking for more

Yes, but I want to lower my rate

No, I do not have coverage

If you qualify for coverage, who will be your beneficiary?

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Would you like to leave more money to your beneficiary or just pay for your funeral expenses? *

Yes, I want to leave additional funds

Yes, I would like to accomplish both

No, I just want to cover my funeral expenses

Do you have a checking or savings account that is in good standing to pay for your monthly premiums? *

Yes

No

Can you give me an idea of how much a Funeral cost in your area today? *

Have you ever had to deal with someone in your family or a friend passing away without insurance? If so, how did they pay for their loss? *

Be truthful when answering all the health questions. Most life insurance companies will verify your information with the Medical Insurance Bureau (MIB) by using your social security number. The MIB gathers data about your healthcare and prescription histories with your consent to assess your risk and eligibility during the underwriting process. It's essential to answer all health-related questions honestly.

Are you currently hospitalized or in a nursing facility? *

Yes

No

Have you been hospitalized two or more times in the past 10 years? *

Yes

No

Have you ever been diagnosed with cancer or had a stroke? *

Yes

No

In the past 10 years, have you used any form of tobacco or nicotine products? *

Yes

No

In the past 5 years, have you used any form of tobacco or nicotine products? *

Yes

No

In the past 10 years, have you had a blood pressure reading over 135/85? *

Yes

No

Height

Weight

Ft. *

In. *

Lbs. *

Do you take any Medications? *

Yes

No

Medications

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Why you use it?

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