Finding out what affordable Life Insurance programs you qualify for can be determined by answering a few simple questions
Answering these questions will:
Pre-qualify you for the best program available to you
Significantly speed up the process. We will shop
100's of programs for you based on your specific
health conditions and the prescriptions you take.
Please answer as honestly and accurately
as you can so we can determine the best fit for you.
What is your age?
Age
50
51
52
53
54
55
56
57
58
59
60
61
62
63
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What is your height and weight?
Have you used any tobacco products in the last 12 months?
Yes
No
What type of tobacco products have you used?
Have you ever been diagnosed by a doctor with asthma, COPD, Emphysema, or any other lung condition?
Yes
No
Have you ever been diagnosed with any diabetic complications such as neuropathy, retinopathy, diabetic coma, or amputation caused by diabetes?
Yes
No
Have you been diagnosed or treated for any heart condition, such as heart attack, bypass surgery, stent placement, or congestive heart failure?
Yes
No
Have you been diagnosed or treated for any strokes, TIA, mini-strokes, or other circulatory issues?
Yes
No
Have you had any seizures?
Yes
No
Have you been diagnosed or treated for any type of cancer?
Yes
No
Have you been diagnosed or treated for depression, schizophrenia, or bipolar disorder?
Yes
No
Are you being treated for any other major health issues?
Have you had any new prescriptions or changes to dosages to your current prescriptions in the past three years?
Have you taken any medications for heart or stroke such as Carvedilol, Coreg, Clopidogrel, Plavix, Isosorbide, Nitroglycerin, or other heart/stroke medications?
Yes
No
Have you taken any water pills such as furosemide or hydrochlorothiazide?
Yes
No
Have you taken any medications that help with your memory such as donepezil, aricept or others?
Yes
No
Do you take any inhalers?
Yes
No
Do you take any medications for cancer treatment such as Anastrozole, Letrozole, Arimidex, or others?
Yes
No
Do you take any medications for any mental health conditions such as Abilify, Seroquel, Lithium, or others?
Yes
No
Let's See What Discounts You're Eligible To Receive? Do You Have a State ID?
Yes
No
Do you do business with a local bank, credit union or use a government-issued direct express card (don't worry, we do not want any personal information. Just a yes or a no.)
Yes
No
What is your monthly budget to spend on your final expenses?
Select an option...
$59-$79 per month
$79-$99 per month
$99-$129 per month
Other
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What is the relationship of the beneficiary to you?
Email
*
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