Term Life Insurance quote
Step 1 of 3
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Date of Birth
Tabacco/Nicotine last use
Current User (1 pack a day
Current user (more than 1 pack a day)
Used in the last year
Last use over 1 year
Last use over 2 years
Last use over 3 years
Last use over 4 years
Last use over 5 years
How you would define your Health Class
Best Class - excellent health condition
Preferred -very good health condition
Standard Plus - good with minor problems
Standard - Standard health condition, minor issues
Rated - Have serious issues with my health
Please enter a number from
Please enter amount you would like to be insured e.g. $75000, $100,000, $750,000, $1,000,000
Period to be insured
Other (please put info in notes)
You have filled quick quote information
Would you like answer several more questions to get a more accurate quote?
This will lead to more questions
Where do your cholesterol levels fall?
Cholesterol - <=220 and HDL ratio - <=5.0
Cholesterol - <=250 and HDL ratio - <=6.0
Cholesterol - <=280 and HDL ratio - <=6.5
Cholesterol - <=300 and HDL ratio - <=7.5
Cholesterol - >300 and HDL ratio - >7.5
Where does your normal Blood Pressure reading fall?
Blood Pressure <= 135/85
Blood Pressure <= 140/85
Blood Pressure <= 140/90
Blood Pressure <= 145/90
Blood Pressure <= 150/90
Blood Pressure <= 155/90
Blood Pressure >155/90
Have any of your parents or siblings been diagnosed or died from Diabetes, Cancer or any Cardiovascular disorder prior to the age of 60?
Have you ever been diagnosed, treated, prescribed medicine or advised to seek treatment by a member of the medical profession of any of the following?
Heart and Circulatory Disorders/Conditions
Chronic Renal Failure, Cirrhosis, AIDS, HIV, or AIDS Related Complex (ARC)
Depression or Emotional Disorders/Conditions
Have you ever been treated or advised to seek treatment for alcohol or drug use?
Have you used any recreational drugs during the past 5 years?
Are you taking any prescription medications or do you have any other health conditions, not already mentioned?
Do you have any felony charges pending or are you on Probation for a Felony?
Are you currently participating in any Aviation or Scuba related activities?
Private Pilot or Student Pilot
Scuba Diving more than 100 feet in depth
Do you currently, or do you have any plans to participate in any of the following activities?
Power Boat racing > 100mph
Automobile or Motorcycle racing
Mountain Climbing >= 13,000 feet
Other extreme sports (bungee jumping, canyoing, street luge)
How many moving violations have you had in the last 3 years?
Less than or equal to 2 in the last 3 years
No more than 3 in the last 3 years
No more than 4 in the last 3 years
More than 4 in the last 3 years
Have you ever had a DUI or reckless Driving conviction?
Have you filed for bankruptcy in the past 7 years?
This iframe contains the logic required to handle Ajax powered Gravity Forms.