Enter as much information as possible. The underwriting engine can only give results on the answers given. Missing or incomplete categories will not factor into the decision.

General Questions

1. What is your gender?

2. Enter your age or date of birth / /

3. Have you ever used tobacco or nicotine products?

4. Height:

5. Weight: lbs

6. Do you know your blood pressure information?

7. Do you know your cholesterol information?

8. Have you ever had, been told you had or have been treated for any of the conditions listed? If yes, check all that apply.

Alcohol Abuse
Asthma
Cancer
Cirrhosis
COPD (emphysema)
Coronary Artery Disease
(stents, bypasses, angioplasty, heart attacks)
Crohn's Disease
Depression/Anxiety
Diabetes
Drug Abuse

Epilepsy (seizures)
Hepatitis
Irregular Heartbeat/Palpitations
Kidney Disease
Lupus
Multiple Sclerosis
Peripheral Vascular Disease
Rheumatoid Arthritis
Sleep Apnea
Stroke

9. Are you involved in a hazardous occupation?

10. Are you a US Citizen?

11. Are you a full-time resident of the US with no intent to change status?

12. Do you intend on visiting an underdeveloped country
or a place with political unrest in the next 24 months?

13. Have you ever been convicted of or awaiting trial for a felony?

14. To your knowledge, is there any family history (parent or siblings) of death before the age of 70 due to cardio/cerebral vascular disease, diabetes, or cancer?

15. Check one or more of the following motor vehicle related incidents if they occured within the past 10 years.

Moving Violation Reckless Driving DUI/DWI License suspended/revoked

16. In the past 5 years have you, or do you intend to participate in any activities listed?

Flying
Sky Diving

Racing
Scuba Diving