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How old are you?
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21
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25
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28
29
30
31
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33
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95
96
97
98
99
100
What is your gender?
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Male
Female
What is your height?
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4'0"
4'1"
4'2"
4'3"
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
What is your weight?
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100 - 120 lbs
121 - 140 lbs
141 - 160 lbs
161 - 180 lbs
181 - 200 lbs
201 - 220 lbs
221 - 240 lbs
241 - 260 lbs
261 - 280 lbs
281 - 300 lbs
301 - 320 lbs
321 - 340 lbs
341 - 360 lbs
361 - 380 lbs
381 - 400 lbs
Within the past 12 months, have you used tobacco?
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Yes
No
Have you been treated or prescribed medications for any of the following conditions?
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Anxiety or Depression
Heart or Circulatory Disorder
Chronic Illness
Diabetes
Respiratory Disorder
Cancer
Bipolar Disorder
Other Medical Condition(s)
No Medical Conditions
Are you married?
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Yes
No
Do you have any children?
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Yes
No
How many children do you have?
None
1
2
3+
What is the age of your youngest child?
Do you plan to help fund college expenses for any of your children?
Yes
No
Are you looking for this policy to cover your final expenses?
Yes
No
What type of funeral are you planning to have?
Traditional Burial
Cremation
I'm Not Sure
What is your current job status?
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Retired
Currently Employed
On Disability
Homemaker/Other
How much total income do you make per year?
$10,000 - $15,000
$15,000 - $20,000
$20,000 - $25,000
$25,000 - $30,000
$30,000 - $35,000
$35,000 - $40,000
$40,000 - $45,000
$45,000 - $50,000
$50,000 - $55,000
$55,000 - $60,000
$60,000 - $65,000
$65,000 - $70,000
$70,000 - $75,000
$75,000 - $80,000
$85,000 - $90,000
$90,000 - $95,000
$95,000 - $100,000
$100,000 +
Do you have a mortgage?
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Yes
No
Do you have any other debt?
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Yes
No
Phone
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Name
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First
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Zip Code
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