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Life Insurance Questionnaire

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    • Alabama
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  • 5
    $500,000
    • Please Select
    • Less Than $25,000
    • $25,000
    • $50,000
    • $75,000
    • $100,000
    • $125,000
    • $150,000
    • $175,000
    • $200,000
    • $225,000
    • $250,000
    • $275,000
    • $300,000
    • $350,000
    • $400,000
    • $450,000
    • $500,000
    • $550,000
    • $600,000
    • $650,000
    • $700,000
    • $750,000
    • $800,000
    • $850,000
    • $900,000
    • $950,000
    • $1,000,000
    • $1,250,000
    • $1,500,000
    • $1,750,000
    • $2,000,000
    • $2,500,000
    • $3,000,000
    • $3,500,000
    • $4,000,000
    • $4,500,000
    • $5,000,000
    • $5,500,000
    • $6,000,000
    • $6,500,000
    • $7,000,000
    • $7,500,000
    • $8,000,000
    • $8,500,000
    • $9,000,000
    • $9,500,000
    • $10,000,000
    • Other Amount
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    Please Select
    • Please Select
    • Term Life Insurance
    • ROP-Return of Premium Term Life
    • Universal Life Insurance
    • Whole Life Insurance
    • Not Sure Yet
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    Please Select
    • Please Select
    • Not Sure Yet
    • 5 Year Term
    • 10 Year Term
    • 15 Year Term
    • 20 Year Term
    • 25 Year Term
    • 30 Year Term
    • Greater Than 30 if Available
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  • 15
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  • 17
    Please Select
    • Please Select
    • 4'-11"
    • 5'-0"
    • 5'-1"
    • 5'-2"
    • 5'-3"
    • 5'-4"
    • 5'-5"
    • 5'-6"
    • 5'-7"
    • 5'-8"
    • 5'-9"
    • 5'-10"
    • 5'-11"
    • 6'-0"
    • 6'-1"
    • 6'-2"
    • 6'-3"
    • 6'-4"
    • 6'-5"
    • 6'-6"
    • 6'-7"
    • 6'-8"
    • 6'-9"
    • 6'-10"
    • 6'-11"
    • 7'-0"
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  • 18
    Insurance companies like to see a stable weight for 12 full month's since they know people try to drop weight prior to applying for insurance
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  • 19
    Please Select
    • Please Select
    • Never
    • Cigarette Smoker
    • Quit Smoking
    • E-Cigarette
    • Cigar-Celebratory Cigar
    • Cigar-Occasional
    • Cigar-Daily
    • Chewing Tobacco
    • Use More Than 1 Type Tobacco
    • Marijuana
    • Other Nicotine Products
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  • 20
    Did you know that most companies will consider you to be a smoker for 12-24 months after you quit...It is also important to note that the non-smoker rate classes will vary by company and time since you quit.
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  • 21
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  • 22
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  • 23
    Don't worry if you do not have exact spelling. It's most important from underwriting standpoint to know why you are taking something.
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  • 28
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  • 29
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  • 30
    Please Select
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    • Afghanistan
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    • Northern Mariana
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    • Republic of the Congo
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