Step 1 of 8 12% Name* First Middle Last Suffix Date of Birth* MM DD YYYY Are You a US Citizen?*YesNoUnknownUnansweredImmigration Status*Permanent Resident/Green Card HolderVisa HolderCountry of Birth*Date of Entry* MM DD YYYY Visa Type*Visa Expiration Date* MM DD YYYY Preferred Contact Type*HomeWorkMobilePreferred Contact Number*Email Address* Current Physical Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Are You Currently Employed?*YesNoUnknownUnansweredOccupationAnnual Earned Income ($)Please Select*Stay at home parentRetired Amount of Insurance ($)*Will This Replace Existing Insurance?*YesNoGuaranteed Term Years* 10 15 20 25 30 Preferred Premium ModeAnnualMonthly Bank DraftHave you applied for life, LTC, disability or health insurance within the last year?*YesNoUnknownUnansweredPlease Specify Insurance CompanyPlease Specify Type of Insurance*Status of the application*PendingApprovedIssuedDeclinedPlease provide first and last name of any spouse/partner who may also be requesting quotes First Last In the last five years, have you used tobacco in any form including cigars, cigarettes, pipe, chew, or nicotine products such as nicotine patch, nicotine gum, or e-cigarettes / vapor?*YesNoUnknownUnansweredTobacco/Nicotine TypesType of Tobacco/NicotineAmount/FrequencyDate Last Used Have you used marijuana in the last 5 years?*YesNoUnknownUnansweredPlease describe details including frequency, date last used, how it is used (smoked, ingested, etc.), recreational or medical use and if medical use, do you have a prescription and what is the diagnosis? Do you consume alcohol?*YesNoUnknownUnansweredAlcohol ConsumptionType of AlcoholHow Much?How Often? Are you planning to reside or travel outside the United States in the next 2 years?*YesNoUnknownUnansweredPlanned List of TravelCityCountryPurposeDatesDuration This is primarily to determine whether you are going to high risk countries.Have you ever been charged with a DUI/DWI, reckless driving, or had your driver’s license revoked or suspended?*YesNoUnknownUnansweredPlease provide details such as violation type, arrest date, conviction date and any loss of license/probation/recommended counseling: Have you had any other motor vehicle/moving violations in the past 5 years?*YesNoUnknownUnansweredPlease provide description (such as: speeding, accident, red light running, etc...) and approximate month/year of any violations: * In the past 5 years, have you engaged (or do you have plans to engage) in SCUBA diving, rock climbing (other than indoor/gym), vehicle racing, sky diving, or any other hazardous sports?*YesNoUnknownUnansweredSCUBA Diving?*YesNoUnknownUnansweredHave you performed any dives in the past 12 months?*YesNoUnknownUnansweredNumber of dives under 50 feet?Avg time underwater per dive?Number of dives between 50 and 75 feet?Avg time underwater per dive?Number of dives between 76 and 100 feet?Avg time underwater per dive?Number of dives over 100 feet?Avg time underwater per dive?Are you contemplating any dives within the next 36 months?*YesNoUnknownUnansweredNumber of Dives and Average Time Per DiveNumber of DivesDepth RangeAverage Time Per Dive Please break dive depths out into the following ranges: Dives under 50 ft, Between 50 ft and 75 ft, Between 76 ft and 100 ft, Over 100 ft.Maximum Depth You Have DivedWhat are the locations of your diving activities? Lakes and rivers Oceans/beaches Caves Deep sea Bays and inlets Other Are you a certified diver?YesNoUnknownUnansweredCertified Diver DetailsName of Certifying OrganizationHours of InstructionDate of Certification Please provide any other information you feel would help us in evaluating your application: Rock Climbing?YesNoUnknownUnansweredVehicle Racing/Stunts?YesNoUnknownUnansweredSkydiving?YesNoUnknownUnanswered HeightWeightSexMaleFemaleAre You Currently Pregnant?YesNoUnknownUnansweredWhat's your approximate due date?How much weight have you gained so far?Are you currently undergoing IVF?YesNoUnknownUnansweredPlease provide details including treatments, procedures and dates Even if not currently pregnant, have you had a history of gestational diabetes, complications or a history of multiple births with any pregnancies? Have you had any weight loss or gain of more than 10 lbs. in the last year?YesNoUnknownUnansweredPlease indicate amount of weight gain or loss, and reason: Have you EVER been diagnosed with, treated for, hospitalized for or been advised to seek treatment for:High blood pressure?*YesNoUnknownUnansweredPlease provide date of diagnosis, medications (name, dosage, and frequency), last date of treatment (if applicable), & last reading/test result High cholesterol or high triglycerides?*YesNoUnknownUnansweredPlease provide: Specific condition/diagnosis, date of diagnosis, any medications (name, dosage and frequency), last date of treatment (if applicable), and last reading/test result Heart attack or coronary artery disease?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Heart murmur, angina or chest pain, palpitations, irregular heart beat or other heart conditions?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Circulatory system disorder, thrombophlebitis, aneurysm, embolism, peripheral vascular disease or edema?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Migraines or chronic headaches?YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, any medications (name, dosage and frequency), & how many work days you miss per year due to this condition: Seizures, fainting, dizziness, vertigo, epilepsy, stroke or mini stroke (TIA – transient ischemic attack), paralysis, carotid artery blockage, or other nervous system or brain disorder?YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Cancer, melanoma, precancerous lesion, lymphoma, or disorder of the lymph nodes?*YesNoUnknownUnansweredCancer TypeBreastProstateTesticularBasal Cell CarcinomaSquamous Cell CarcinomaMalignant MelanomaDysplastic NeviA further questionnaire will be provided to collect more details.Anemia, leukemia, clotting disorder, or any other blood disorder?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Diabetes, elevated blood sugar, a disorder of the urinary tract or findings of sugar, protein or blood in the urine?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) * Asthma?*YesNoUnknownUnanswerablePlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Sleep apnea?*YesNoUnknownUnansweredWhat type of sleep apnea do you have?ObstructiveCentralMixedUnknownHow was it characterized?MildModerateSevereUnknownDid you have a sleep study to diagnose?YesNoUnknownUnansweredAre you on any treatment such as CPAP, BIPAP, mouth guard or other?YesNoUnknownUnansweredPlease describe: With treatment, do you continue to experience persistent fatigue? Are you compliant with your treatment?YesNoUnknownUnansweredPlease include any additional details: Example: Nightly use of CPAPHave you had a follow-up sleep study?YesNoUnknownUnansweredWhen was the follow-up conducted and what were the results? Emphysema, chronic obstructive pulmonary disease (COPD), shortness of breath, tuberculosis, sarcoidosis, persistent hoarseness, bronchitis or any other disorder of the lungs or respiratory system?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency)* Arthritis, osteoporosis/osteopenia, gout, fibromyalgia, carpal tunnel or any injury/disorder of the back, spine, muscles, nerves, bones, joints or skin?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Alcohol or drug abuse?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency)* Colitis, Crohn’s disease, Celiac disease, diverticulitis, or IBS?*YesNoUnknownUnansweredDate of first diagnosis?*When was your last flare?*Please note the type of inflammatory bowel disease present: Chronic ulcerative colitis Chronic proctitis (inflammation in rectum only) Crohn’s disease Celiac disease Diverticulitis IBS Have you had any hospitalizations for this disorder?*YesNoUnknownUnansweredPlease list dates: Have you had any surgeries for this disorder?*YesNoUnknownUnansweredPlease list dates: Have you had any colonoscopies?*YesNoUnknownUnansweredPlease list dates: Elevated liver functions, ulcers, jaundice, hepatitis, cirrhosis, gastrointestinal bleeding, or other disorder of the stomach, esophagus, liver, intestines, gallbladder or pancreas?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency)* Disorder of the reproductive organs, or sexually transmitted diseases?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency)* Thyroid, pituitary or other endocrine or glandular disorder?YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Anxiety?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Depression?YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency)* ADD, ADHD or any other nervous, mental, emotional, mood or eating disorders?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Alzheimer's or other cognitive disorder?YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency)* Have you ever attempted suicide or had suicidal thoughts/ideations?YesNoUnknownUnansweredPlease describe: Any disorder of the eyes, ears, nose or throat?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Ever been diagnosed or treated for AIDS or AIDS related conditions or tested positive for the presence of HIV antibodies, antigens or the virus?*YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency)* Ever been treated for or been diagnosed as having an immune deficiency disorder other than AIDS?YesNoUnknownUnansweredPlease provide specific condition/diagnosis, date of diagnosis, treatments, & any medications (name, dosage and frequency) Are you planning to seek medical advice or treatment for any reason; are you scheduled for a medical test or appointment or have you been advised to schedule a follow up medical appointment or test?*YesNoUnknownUnansweredPlease provide doctor's contact information, date/reason for visit, and any diagnostic tests being performed (if applicable):* Have you had any hospitalizations or surgeries in the last 10 years?*YesNoUnknownUnansweredPlease provide details about dates, treatments, medications and dosages, and follow-ups.* Are you currently taking any other medications or supplements other than those listed above?YesNoUnknownUnansweredPlease describe:* In the last 5 years, were you prescribed any medications that you are NOT currently taking, other than cold, flu or birth control?*YesNoUnknownUnansweredPlease provide the diagnosis, medication name, dosage and dates taken and if the condition is resolved:* Family History - MotherIs your biological mother living?*YesNoUnknownUnansweredCurrent AgePresent HealthDoes she have a history of heart/cardiovascular disease, stroke, cancer, or diabetes? If so, please provide type and age at onset:* Age at DeathCause of DeathDid she have a history of heart/cardiovascular disease, stroke, cancer, or diabetes? If so, please provide type and age at onset: Family History - FatherIs your biological father living?*YesNoUnknownUnansweredCurrent Age*Present Health*Does he have a history of heart/cardiovascular disease, stroke, cancer, or diabetes? If so, please provide type and age at onset: Age at DeathCause of DeathDid he have a history of heart/cardiovascular disease, stroke, cancer, or diabetes? If so, please provide type and age at onset: Family History - SiblingsDo you have any living or deceased biological siblings with history of heart/cardiovascular disease, stroke, cancer, or diabetes?*YesNoUnknownUnansweredPlease list gender, age, and condition(s) of each sibling: Example: Brother, living, age 54, diagnosed with heart disease at age 50 Δ
