Instant insurance quote
Pesonal Information
Age
Coverage
$5,000
$10,000
$25,000
Gender:
Male
Female
Smoking
Within the past 10 years, have you used any tobacco or nicotine products, including cigarettes, cigars, e-cigarettes, or chewing tobacco?
Yes
No
In the past two years, have you smoked or used any form of tobacco at a rate of more than one pack per week?
Yes
No
Have you ever been advised by a medical professional to quit smoking or using tobacco products?
Yes
No
Diabetes
Have you been diagnosed with diabetes, elevated blood sugar, thyroid, adrenal, pituitary or pancreas disorder or any other gland or endocrine disorder within the past 10 years?
Yes
No
Are you currently being treated, or have you ever been treated, for diabetes with medication, insulin, or other therapies?
Yes
No
Within the last 5 years, have you experienced complications related to diabetes, such as neuropathy, retinopathy, or kidney issues?
Yes
No
Family Medical History
Do you have any family history of heart disease, diabetes, cancer, or other serious health conditions diagnosed in your parents or siblings before the age of 60?
Yes
No
Has any member of your immediate family (parents, siblings) been diagnosed with high blood pressure, elevated cholesterol, or suffered from a stroke or heart attack?
Yes
No
Is there a history of hereditary conditions, including diabetes or cancer, in your family that may increase your health risk?
Yes
No
Hazardous Occupation
Are you currently employed in an occupation that involves hazardous activities such as heavy machinery operation, mining, chemical handling, or exposure to toxic substances?
Yes
No
Have you engaged in high-risk occupational activities within the past 2 years, including but not limited to firefighting, construction, deep-sea diving, or aviation?
Yes
No
Within the past 5 years, have you participated in any occupation that requires you to work with hazardous materials or involves a significant risk of injury?
Yes
No
Alcohol Consumption
Within the past five years, have you consumed alcohol at a level exceeding two drinks per day, or been advised by a healthcare provider to reduce your alcohol intake?
Yes
No
Have you ever been treated, or advised to seek treatment, for alcohol dependency or abuse by a medical professional?
Yes
No
Within the last year, have you been involved in any incidents or medical conditions related to alcohol consumption?
Yes
No
Serious Medical History
In the past 10 years, have you been diagnosed, treated, or received medical advice for any serious medical condition, including cancer, heart disease, kidney disease, liver disease, or neurological disorders?
Yes
No
Within the past five years, have you consulted with a medical professional regarding any life-threatening or chronic illness that required regular treatment or monitoring?
Yes
No
Have you been advised within the past two years to undergo surgery or advanced medical testing, such as an MRI or biopsy, for a serious medical condition?
Yes
No
Result
Total Annual Premium
$0
Total Semi Annual Premium
$0
Total Quarterly Premium
$0
Total Monthly Premium
$0
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