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Applicant Information

First Name

Last Name

Applicant Information

Email Address

Applicant Information

Are you applying to insure your own life?

My own life Someone else's

Applicant Information

What's your home address?

Please add in the missing details

Street and Number

City

State

Zipcode

I'll need some basic info about you

Height

Weight

DOB

Gender

Male Female

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Do you have any life insurance or annuities currently in force or pending?

Yes No

What is the total coverage amount in force or pending?

Do you have any COVID 19 in last 30 days

Yes No

Do you have any loose weight more than 10 pound in last 6 month?

Yes No

How Much you loose?

Are you currently admitted to a

Hospital Long-term care facility Hospice

In the past 12 months, have you used

Cigarettes, E-cigarettes, pipes, vapor products, snuff, chewing tobacco, nicotine gum or nicotine patches?

Yes No

Have you ever tested positive for HIV?

Yes No

In the past 12 months, have you received disability payments?

Yes No

Why did you receive disability payments?

Maternity or paternity leave

Worker's compensation

Short-term disability

Long-term disability

Social Security Disability Income (SSDI)

Veterans Affairs disability income

Other

Are your disability benefits solely due to hearing or visual impairments?

Yes No

In the past 12 months, has a medical professional advised you to have

Surgery

Any test or procedure (other than for HIV)

In the past 10 years, have you been diagnosed or treated by a medical professional for

Heart disease

Stroke or mini-stroke/TIA

Seizure disorder

Chest pain

Organ transplant

Peripheral arterial disease

Chronic kidney disease

Liver cirrhosis

Chronic obstructive pulmonary disease

Have you had a biological parent die before age 60 from any of the following

Heart disease

Melanoma

Colon cancer

Ovary or breast cancer

In the past 12 months have you been

Confined to a wheelchair

Diagnosed or treated by a medical professional for memory impairment

Required to use supplemental oxygen

Assisted or supervised with dressing, eating, bathing or walking

Are you a U.S. Citizen?

Yes No

Where were you born?

The U.S. or U.S. Territories Elsewhere

Country

What's your employment status?

Working full-time

Working part-time

Full-time student

Part-time student

Stay at home spouse or partner

Not working

Retired

I'll need some info about your finances

What’s your annual income?

Estimated household income

In the next 2 years, do you plan to

Pilot an aircraft

Scuba dive

Race a motor vehicle

Mountain or rock climb

Skydive

In the past 2 years have you been declined for life insurance?

Yes No

Please select one

Medical Criminal history Other I'm not sure

In the past 10 years, have you been convicted, pleaded guilty to or have charges pending for a

Misdemeanor

Felony

DUI/DWI for alcohol or drugs

How many alcoholic drinks do you typically have per week?

In the past 10 years, have you used

Cocaine, methamphetamines, heroin, opioids, hallucinogens or any controlled substance not prescribed to you by a physician?

Yes No

In the past 12 months, have you used any form of marijuana?

Yes No

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We are Find A Plan, a company dedicated to providing quality insurance policies and consultation for all types of needs. Whether you need medical insurance, pet coverage, or life insurance, we have partner professionals to help you out. We pride ourselves on our customer service and making sure that everyone who comes to us walks away with the right policy for their needs. Contact us today to get started!