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Life Insurance Quote Request
About 3 minutes is all it takes to get accurate life insurance quotes!
Your life insurance quote request is sent to me,
Mike Horbal
, the owner of RiskQuoter. We don't sell your information to others, and there's never any pressure or obligation.
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Step
1
of 9
Where do you live?
*
-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
Next
What is your gender?
*
Female
Male
When were you born?
*
MM
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Next
Have you ever used tobacco/nicotine?
*
-Select-
Never
Former Tobacco User
Cigarettes
Cigars
Chewing Tobacco
E-cigarettes or Vape
Marijuana
When did you quit?
How often do you smoke cigars?
Celebratory (1-2 times per year)
Up to 12 times per year
Up to 24 times per year
Daily cigar smoker
Non-tobacco rates are available for all cigar smokers!
Do you have a medical marijuana prescription?
Yes
No
Why were you prescribed medical marijuana?
How often do you use marijuana?
Please Select
Infrequent (2x or less per year)
Occasional (couple times per year)
Monthly
Weekly
Daily
How do you use marijuana?
Smoke
Vape
Edibles
Pills
Sprays or Topical
Tinctures
Check all that apply as rules may vary with some companies.
Next
How much life insurance do you need?
*
-Select-
Less than $25,000
$25,000
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$500,000
$600,000
$700,000
$800,000
$900,000
$1,000,000
$1,500,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000 or Greater
How long do you need coverage for?
*
-Select-
10 Year Term
15 Year Term
20 Year Term
25 Year Term
30 Year Term
35 Year Term
40 Year Term
Lifetime Coverage
Not Sure Yet
Next
How tall are you?
*
Select
4'-11"
5'-0"
5'-1"
5'-2"
5'-3"
5'-4"
5'-5"
5'-6"
5'-7"
5'-8"
5'-9"
5'-10"
5'-11"
6'-0"
6'-1"
6'-2"
6'-3"
6'-4"
6'-5"
6'-6"
6'-7"
6'-8"
6'-9"
6'-10"
6'-11"
7'-0"
How much do you weigh?
*
Select
95
96
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400
Greater than 400
Next
Do you participate in:
Private Aviation
Scuba Diving
Rock or Mountain Climbing
None of these
What type of pilot certificate do you have?
Student Pilot
Sport Pilot
Private Pilot
Commercial Pilot
Airline Transport Pilot
When did you obtain your pilot certificate?
Month and year
Do you have your Instrument Rating?
Yes
No
What is the Make and Model of the aircraft you fly?
Do you expect to change the aircraft you fly in the next 24 months?
Yes
No
Have you ever had any FAA violations?
Yes
No
How many total flying hours do you have?
How many hours did you have last year?
How many hours do you have year to date?
How many hours do you expect to have next year?
Next
Have you ever been diagnosed with or treated for:
None of these
High Blood Pressure
Respiratory Problems
Heart Conditions
Mental or Nervous Disorder
Cancer History
Immune System Disorders
Gastrointestinal Problems
Brain - Stroke, Epilepsy
Endocrine Disorders
Drug and/or Alcohol Abuse
HIV Positive
Other Health History
What were you diagnosed with?
How is your medical condition treated?
Please list any surgeries, medications and dosages here. Include dates
Next
What type of heart condition do you have?
Abdominal Aortic Aneurysm
Coronary Calcium Score
Abnormal EKG
Coronary Artery Disease
Angina
Heart Attack
Angioplasty
Heart Murmur
Aortic Stenosis
Heart Stents
Atrial Fibrillation
Heart Valve Surgery
Bundle Branch Blocks
NT-proBNP
Bypass Surgery
Pacemaker
When were you diagnosed with this heart condition?
Did you have Surgery?
What procedure did you have and what was the date of surgery?
Have you completed all treatment and follow-up tests?
Yes
No
Has any treatment/surgery been recommended that you have not completed yet?
Yes
No
What type of cancer were you diagnosed with?
Bladder Cancer
Prostate Cancer
Breast Cancer
Skin Cancer
Cervical Cancer
Testicular Cancer
Colon Cancer
Throat Cancer
Kidney Cancer
Thyroid Cancer
Lymphoma
Other
What type of cancer did you have?
When were you diagnosed with cancer? (month and year)
What type of breast cancer were you diagnosed with?
Ductal carcinoma insitu (DCIS)
Ductal carcinoma insitu (DCIS)
Invasive ductal carcinoma (IDC)
Invasive lobular carcinoma (ILC)
Triple negative breast cancer
Other
How was the breast cancer treated?
Surgery
Radiation
Chemotherapy
Other
What was the treatment?
Were surgical margins:
Positive
Negative
Close
What was the size of the tumor?
Were any lymph nodes positive? If yes, how many and where were they located?
Were breast cells hormone receptor:
Positive
Negative
What type(s) of skin cancer were you diagnosed with?
Basal Cell Carcinoma
Squamous Cell Carcinoma
Melanoma
What type of thyroid cancer were you diagnosed with?
Papillary
Follicular
Medullary
What was the cancer stage?
In Situ
Stage 1
Stage 2
Stage 3
Stage 4
If you completed genetic testing, please indicate the test name and results here.
What was your PSA level at the time of diagnosis?
What was your Gleason score?
How was the cancer treated?
Active Surveillance
Surgery
Radiation
Chemotherapy
Other
Were surgical margins positive or negative?
Positive
Negative (or clear)
Please provide your PSA test result history since diagnosis
With active surveillance, we need the date and PSA result from each test since diagnosed.
Has there been any recurrence of cancer?
Yes
No
What were the start and stop dates of treatment?
What type of gastrointestinal condition were you diagnosed with?
Crohn's Disease
Elevated Liver Functions
Hepatitis
Ulcerative Colitis
Other
What was your date of diagnosis? (Month & Year)
When was your last flare-up or episode and how long did it last?
How many flare-ups/episodes have you had in the past 6 months?
How many flare-ups/episodes have you had in the past 12 months?
How many flare-ups/episodes have you had in the past 24 months?
How many flare-ups/episodes have you had in the past 5 years?
When was your last colonoscopy and what were the results?
What type of hepatitis were you diagnosed with?
Hepatitis A
Hepatitis B
Hepatitis C
Autoimmune Hepatitis
Have you had treatment to cure hepatitis C?
Yes
No
What are your most recent liver function test results
AST
ALT
ALP
Bilirubin
GGTP
Have you had an ultrasound or liver biopsy completed?
Yes
No
Was there any indication of:
Inflammation
Fibrosis
Cirrhosis
Fatty Liver
Do you drink alcohol?
Yes
No
What type of endocrine disorder do you have?
Addison's Disease
Diabetes
Metabolic Syndrome
Proteinuria
Thyroid Disease
Other
What type of diabetes were you diagnosed with?
Type 1
Type 2
Gestational
How do you control your diabetes?
What are your average lab results for:
HbA1c
Fasting Blood Glucose
Have you had any of these diabetes related complications:
Retinopathy
Neuropathy
Kidney Problems
History of insulin shock or diabetic coma
Surgery or amputation
How often do you visit your physician for checkups and labs
Every 3 months
Every 6 months
Every 12 months
Noncompliant or do not visit doctor
What was your CD4 level at the time of diagnosis?
What was your lowest ever recorded CD4?
Is your current viral load undetectable?
Was HIV acquired via blood transfusion or IV drug use?
Do you visit your physician every 3-6 months?
When were your last viral load and CD4 lab tests completed?
What type of respiratory condition do you have?
Asthma
Sleep Apnea
COPD
Is your asthma considered:
Mild
Moderate
Severe
How often do you have asthma attacks?
Have you been hospitalized for asthma attacks? If yes, how often and when?
What type of sleep apnea do you have?
Obstructive (most common)
Central
Complex
Is your sleep apnea considered:
Mild
Moderate
Severe
When was your last polysomnogram sleep study completed?
What was the Apnea Index (AI)?
What was the Apnea Hypopnea Index (AHI)?
What was the Respiratory Disturbance Index (RDI)?
What was the oxygen saturation percentage?
How is the sleep apnea being treated? (check all that apply)
CPAP, BiPap, VPAP
Oral Appliance
Neural Stimulation Device - Inspire
Surgery
Weight Loss
What condition were you diagnosed with?
Anxiety
Bipolar Disorder
Depression
Eating Disorders
Obsessive Compulsive Disorder
PTSD
Other Condition
How often do you visit with your physician or therapist?
Is your condition considered:
Mild
Moderate
Severe
Have you ever been hospitalized for this condition?
Yes
No
Please provide dates of hospitalization(s) and reason for visit.
Have you received disability benefits in the past 5 years?
Yes
No
Please provide dates and reason for receiving disability?
Were you diagnosed with:
Epilepsy
Multiple Sclerosis
Stroke or TIA
Other
What is your exact diagnosis?
What types of seizures have you had?
Focal Onset Seizures (aware seizures, impaired awareness)
Generalized Seizures (absence, myoclonic, tonic clonic)
Unknown Onset Seizures
How often do you have seizures?
When was your last seizure?
Have you been hospitalized for epilepsy? If yes, when?
Do you have any history of status epilepticus?
Yes
No
Have you had any mental deterioration or personality changes from epilepsy?
Yes
No
When was your last EEG, MRI, or CT scan completed?
What type of MS do you have?
Relapsing Remitting (RRMS)
Secondary Progressive MS (SPMS)
Primary Progressive MS (PPMS)
Clinically Isolated Syndrome
How many attacks per year do you have on average?
What was the date of your last episode?
What symptoms and complications do you have from MS?
Do you fully recover in between episodes?
Have you developed any cognitive impairments from MS?
Do you have a history of depression?
Yes
No
What types of tests have you had completed to monitor MS?
Blood tests
Spinal tap
MRI
Evoked potential tests
What are the approximate dates and results of your latest tests?
Did you have a stroke, TIA or both?
Stroke
TIA (mini-stroke)
Both
What caused the stroke or TIA?
Atrial fibrillation
Valve disorders
Heart attack
Carotid artery plaque
Unknown
Have you had any of the following symptoms?
Vision problems
Weakness or paralysis of limbs
Inability or trouble speaking
Dizziness
Other symptoms
Have you had surgery due to the stroke or TIA?
Do you attend AA, NA or other types of therapy?
Yes
No
How often do you attend meetings and/or therapy?
If no, why not?
Have you had any relapses?
Yes
No
What were the approximate dates of relapse, and subsequent treatment dates?
Do you take any medications?
Yes
No
Medication Details
Next
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*
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Last
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Phone
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