Your Profile
Date of birth*
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Year
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Gender*
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State*
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Tobacco/Nicotine Use*
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I have never smoked.
I quit over 5 years ago.
I quit 3-5 years ago.
I quit 2-3 years ago.
I quit 1-2 years ago.
I quit less than 1 year ago.
I smoke no more than 1 pack a day.
I smoke more than 1 pack a day.
I smoke cigars.
I smoke a pipe.
I chew tobacco.
I smoke an e-cigarette.
I am on "The Patch."
I chew nicotine gum.
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Health Level* How do I determine my health level?
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Excellent
Good
Fair
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Excellent (Preferred Plus)
You are in excellent overall health with no history of drug or alcohol abuse. You have a good driving record and don’t engage in hazardous activities. There’s no history of heart disease (sometimes cancer) among your parents or siblings prior to their age 60.
Good (Preferred)
You are in pretty good overall health, have a good driving record, and you don’t participate in any hazardous activities. You may have some family history of heart disease or cancer and have some minor health issues.
Fair (Standard)
You’ve had some health issues. Your cholesterol levels may be elevated or you may be overweight. The extent of your health issues will determine what rate you may qualify for.
Coverage Type
35-Year Guaranteed Level Term
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20-Year Guaranteed Level Term
15-Year Guaranteed Level Term
10-Year Guaranteed Level Term
Coverage Amount Not sure? Use our calculator.
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$7,500,000
$10,000,000
Please Select Coverage Amount
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Contact Info
First Name*
Please fill in first name. Must be at least 2 characters.
Last Name*
Please fill in last name. Must be at least 2 characters.
Date of birth*
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Please select complete date of birth
Gender*
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Male
Female
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State*
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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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