Get a Quote! Life Insurance 1 Personal Information 2 Additional Information Have you used tobacco or other nicotine related product? Never Less than a year 2 years 3 years 4 or more years Are you being treated for high blood pressure or cholesterol? Yes No Are you currently being or have you ever been treated for alcohol or drug use? Never More than 5 years ago Less than 5 years ago Have any of your parents or siblings died prior to age 60 from cancer, stroke or a heart disorder? No One death More than one death Have you ever had any DUI or reckless driving charges? No Yes, less than 5 years ago Yes, more than 10 years ago Do you participate in hazardous sports? Yes No Coverage Amount 50,000 100,000 200,000 400,000 600,000 700,000+ Insurance term 5 years 10 years 15 years 20 year + Back Send
