Complete our online form below for yourself and/or other family members to receive a no-obligation quote tailored to each individuals specific age, health, and coverage needs.

Michigan residents only.

Name(Required)
Address(Required)

Underwriting Questionnaire

MM slash DD slash YYYY
Gender
Have you used any tobacco products?

Have you been treated or sought treatment for:

drug or alcohol abuse?
moderate/severe asthma, chronic bronchitis, Crohns, diabetes, epilepsy(seizure w/in 2yrs), gastric/peptic ulcer(treated w/in 2yrs),chronic kidney/liver disease, mental illness, multiple sclerosis, ulcerative colitis?
for depression within the past 2 years?
cardiovascular heart disease, chronic obstructive pulmonary disease, emphysema, stroke(inc. TIA), vascular disease?
Have you or do you plan Gastric by-pass surgery, or have you lost or gained more than 10 pounds in the past two years?
Have you lost a parent or sibling to an early death due to heart attack, stroke, or cancer?
Is your blood pressure normal?
Is your cholesterol level normal?
In past 5 years have you had 3 or more traffic violations or been convicted of D.U.I. (Driving Under the Influence)?
Any hazardous occupation/hobbies?
Plans to travel to underdeveloped or unstable countries?

I am interested in:

Duration of plan

Completing a request for an illustration (quotation) does not guarantee that a policy will be issued or will it obligate you to accept a policy.