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 shop 100s 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.

Upon completion we will deliver the results to you in less than 24 hours.

What is your age? *

What is your height and weight? *

Have you used ANY tobacco products in the last 12 months? *

Yes

What kind of tobacco products have you used? *

Have you ever been diagnosed by a doctor with asthma, COPD, Emphysema, or any other lung condition? *

Yes

What kind of lung condition have you been diagnosed with by a doctor? How long ago were you diagnosed *

Have you ever been diagnosed with Diabetes? *

Yes

At what age were you when you were diagnosed with diabetes? *

Have you ever been diagnosed with any diabetic complications such as neuropathy, retinopathy, diabetic coma, or amputation caused by diabetes? *

Yes

What diabetic complications have you had? *

Do you currently take insulin? *

Yes

What age did you start taking insulin? *

Have you been diagnosed or treated for any heart condition, such as heart attack, bypass surgery, stent placement, or congestive heart failure? *

Yes

When were you first diagnosed with this heart condition? *

Have you been diagnosed or treated for any strokes, TIA, mini-strokes, or other circulatory issues? *

Yes

What type of circulatory issues did you have? When did your last occurrence happen? *

Have you ever had any seizures? *

Yes

How many seizures do you have a year? How long ago were you diagnosed? *

Have you been diagnosed or treated for any type of cancer? *

Yes

Have you been diagnosed with more than one occurrence of cancer in your lifetime? *

Have you been diagnosed or treated for depression, schizophrenia, or bipolar disorder? *

Yes

What type of mental health diagnosis have you had by a doctor? *

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

What heart meds have you taken? What condition requires you to take that medication? *

Have you taken any water pills such as furosemide or hydrochlorothiazide? *

Yes

What water/fluid pills have you taken What condition requires you to take that medication? *

Have you ever taken any medications that help with your memory such as donepezil, aricept or others? *

Yes

What memory pills have you taken? What condition requires you to take that medication? *

Do you take any inhalers? *

Yes

What inhalers do you take? What condition requires you to take that medication? *

Do you take any medications for cancer treatment such as Anastrozole, Letrozole, Arimidex, or others? *

Yes

What cancer medications do you take? What condition requires you to take that medication? *

Do you take any medications for any mental health conditions such as Abilify, Seroquel, Lithium, or others? *

Yes

What mental health meds do you take? What condition requires you to take that medication? *

Do you have a state ID? *

Yes

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

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's the name of your beneficiary? *

What is their relationship to you? *

Email *