Secure Life Application

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Click > next to complete this SSL secure application which we can use for over 121 different insurance companies.

Since 1969 We have helped thousands of people get the best rate and value.

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Verify Legal Name* This field is required.
First, Middle, Last, Suffix
3
State of Residence* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansa
California
Colorado
Connecticut
Delaware
Washington,DC
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Please Verify Home Street Address* This field is required.
Street Address
Unit/Apartment Number
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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How long have you lived at current address?
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Gender* This field is required.
Female
Male
7
Verify Date of Birth* This field is required.
mm/dd/year
8
Social Security # (if uncomfortable providing full #, please provide last 4 digits only)* This field is required.
9
City, State and Country of Birth* This field is required.
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Home or Cell Phone #* This field is required.
Area Code
Phone Number
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Work Phone #
Area Code
Phone Number
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Citizenship* This field is required.
U.S. Citizen
Green Card
Foreign Citizen
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Marital Status* This field is required.
Married
Single
Widowed
Divorced
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Drivers License #, State & Expiration Date* This field is required.
15
Occupation & Duties* This field is required.
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Approx Annual Income* This field is required.
Please Select
Please Select
$10,000+
$12,000+
$15,000+
$20,000+
$25,000+
$30,000+
$35,000+
$40,000+
$45,000+
$50,000+
$60,000+
$75,000+
$100,000+
$150,000+
$200,000+
$250,000+
Homemaker
Including Pension, SS, current employment
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Approx Net Worth* This field is required.
Please Select
Please Select
negative
$0- Zero
$10,000+
$25,000+
$50,000+
$100,000+
$250,000+
$500,000+
$750,000+
$1,000,000+
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Employer Name & Address* This field is required.
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How Long Employed* This field is required.
20
Do You Currently Have Life Insurance?* This field is required.
Yes
No
21
Are You Looking to Replace This Policy?
Yes
No
22
If you have current life insurance, provide company name, policy#, amount, year issued, personal or business
23
Have you had any moving violations in past 5 years* This field is required.
yes
No
24
How Many Moving Violations
1 in past 5 years
3 in past 5 years
2 in past 5 years
4 or more in past 5 years
25
Has Your Drivers License Been Suspended or Revoked in Past 10 Years?* This field is required.
Yes
No
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Why, When and for How Long Suspended?
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In past 5 years have you or do you intend in next 2 years to do any of the following:* This field is required.
Scuba Diving
Private Pilot
Motorized Racing
Skydiving/Parachuting
Mountain/Rock Climbing
Regular Ballooning
Hang Gliding
Ultra Light Flying
Heli-Skiing
Cliff or Base Jumping
I have not engaged in any hazardous activities in past 5 yrs, and don't expect to in next 2 yrs
28
Do you smoke or use tobacco or nicotine in ANY form?* This field is required.
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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How Long Since You Quit?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.
30
What Do You Use?
31
In past 5 years, have you requested workers compensation, social security or disability income payments?* This field is required.
Yes
No
32
Was it workers comp, Social Security, SSDI, group or individual disability income?please specify
33
Have you EVER filed for bankruptcy or are you currently in bankruptcy?* This field is required.
Yes
No
34
Have you ever been convicted of or charged with a felony or misdemeanor, or are you currently on parole or probation?* This field is required.
Yes
No
35
Are you a member of, or do you intend to become a member of the armed forces, including reserves?* This field is required.
Yes
No
Retired
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In the last 2 years have you traveled outside the U.S. or Canada or do you intend to (i.e. already have reservations booked) travel outside U.S. or Canada in next 2 years?* This field is required.
Yes
No
37
Where have you gone, are you going, when are you going and how long will you be there?
Huge
Large
Normal
Small
Ok
Ok
38
Have you ever been declined, postponed, rated (charged higher rate) for life insurance in past?* This field is required.
Yes
No
39
Have you ever sold, transferred or assigned any life insurance policy to a 3rd party, such as to a life settlement company, viatical supplement company or premium financing company?* This field is required.
Yes
No
40
Do you consume alcohol?* This field is required.
never
beer/wine daily
liquor daily
beer/wine weekly
liquor weekly
beer/wine monthly
liquor monthly
special occasions
41
Date & type of last alcohol consumption
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In last 10 years have you used cocaine, marijuana, methamphetamines, barbiturates or other controlled substances not prescribed by a physician? * This field is required.
YESNO
43
Who would you like to name as your primary beneficiary or first in line to receive the insurance, and what is their relationship to you?* This field is required.
44
Who would you like to name as your contingent beneficiary or second in line to receive the insurance, and what is their relationship to you?
45
Please provide name and address or phone # of your personal physician:
46
Please provide name and address or phone # of any medical specialists you see:
47
Unique ID Number
Should be Empty: