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Life quote
Visu4lEdg3
2017-03-01T06:41:53+00:00
Free Life Quote
1
General Info
2
Life Style Info
3
Medical History
Fields marked (*) are mandatory.
Amount of Coverage
(Note: can be changed later)
up to $100.000
$100.000
$150.000
$200.000
$250.000
$300.000
$350.000
$400.000
$500.000
$750.000
$1.000.000
$1.250.000
$1.500.000
$1.750.000
$2.000.000
$2.500.000
$3.000.000
$3.500.000
First name
Last name
Address
Street Address
City
ZIP Code
State of Residence
Please select
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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Home Phone
Year
5 years
10 years
15 years
20 years
25 years
30 years
Gender
Male
Female
Date Of Birth
Date Format: MM slash DD slash YYYY
Marital status
Single
Married
Separated
Divorced
Widowed
Domestic Partner
Unknown
US Legal Status
Please select
US Citizen
Permanent resident or Green Card
Neither
Contact E-mail
Fields marked (*) are mandatory.
Check one or more of the following:
Leave unchecked if you do not find yourself in the above situations.
You are a pilot
You are currently on active military duty
You have a hazardous occupation
You have a hazardous hobby/avocation
You intend to travel to a politically unstable country
Driving record - have you had any violations in last 5 years?
Yes
No
Cigarette Usage
Please select
Never smoked or quit smoking 10 years ago
Quit smoking 5 years ago
Quit smoking 2 years ago
Currently smoking
Have you used tobacco products within the last 10 years?
Yes
No
Fields marked (*) are mandatory.
Systolic Rating
Please select
Bellow 60
60-69
70-79
80-89
90-99
Above 99
Don't know
Diastolic Rating
Please select
100-109
110-119
120-129
130-139
Above 139
Don't know
Received Blood Pressure Treatment
Yes
No
Received Cholesterol Treatment
Yes
No
Have any of your immediate family members had any of the following: heart attack, diabetes, stroke, cancer, or kidney disease
(Note: immediate family members refer to mother, father, or siblings)
Yes
No
Check any of the following conditions for which you have been diagnosed or treated
Central Nervious System
Alzheimer's Disease
Epilepsy
Multiple Sclerosis
Parkinson's' Disease
Circulatory System
Coronary Artery Disease
Stroke
Vascular Disease
Other Heart Disease
Digestive System
Bowel Incontinence
Kidney Disease
Diabetes Mellitus
Gastric/Peptic Ulcers
Kidney Stones (last 2 years)
Neurogenic Bladder
Ulcerative Colitis or Ileitis
Mental Health, Drug Abuse
Drug Abuse
Depression (last 2 years)
Mental Illness
Alcoholism
Respiratory System
Asthma
Chronic Bronchitis
Emphysema
Sleep Apnea
COPD
Cancer
Leukemia
Basal Cell
Squamous Cell
Melanoma
Prostate Cancer
Breast Cancer
Other Cancer
Other
HIV
Rheumatoid Arthritis
