Request a Quote

Step 1 of 3

Name

First Last

Phone

Date of birth

Gender

State of residence

State / Province / Region

Height and Weight

Occupation

Have you ever had trouble getting insurance before (declined, postponed, rated or ridered)? If so, please provide details.

Are you a member of the armed forces or reserves? If so, please provide details.

Ever flown, or presently fly as a pilot? If so, please provide details.

Do you engage in Scuba Diving, Sky Diving, Mountain Climbing, Motorized Racing or any other "hazardous avocations"? If so, please provide details.

Motor Vehicle violations, accidents, or DUI in the last 5 years? If so, please provide details.

Any travel outside the United States or Canada planned in the next two years? If so, please provide details.

Used any form of tobacco within the last 5 years? If so, please provide details.

Used any form of marijuana within the last 5 years? If so, please let us know frequency of use and type used (i.e., smoking vs. edibles, and if smoking if vaping is used).

Any current Prescription Medications? If so, please provide details.

Family History of Cancer or heart disease diagnosed before age 60 (just parents and/or siblings)? If so, please provide details.

If known, Blood Pressure when last checked? Any treatment for High Blood Pressure?

If known, Total Cholesterol when last checked, including HDL level? Any treatment for Cholesterol?

Any personal medical history you think might cause an insurance company to charge you a higher rate?

Are you currently in school, residency, or a fellowship? If so, please provide the name of the school or program.

Will you be moving soon? If so, to which state?

Annual personal income

Have you seen a chiropractor, or have you had any trouble with your back, neck, or other joints? If so, please provide details.

Are you single or do you have a significant other? If the latter, please provide details.

Do you currently have, or do you need, Life Insurance coverage? If so, please provide details. (a lot of the current Long-Term Care options use life insurance to provide the coverage)

Annual household income

Do you currently have individual or group health insurance?

Are you on COBRA?

Would you like to insure any dependents? If so, provide their names and dates of birth.

Would you like to use Qualified (Pension/IRA) or Non-Qualified (personal) money to fund your annuity?

Amount to deposit

Would you like to make a lump sum deposit or annual transfers?

Planned distribution date (immediate or deferred)

Do you want your annuity to help you avoid the Required Minimum Distribution (RMD)?