Life Insurance Quote Request

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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? *

What is your gender? *

Female
Male

When were you born? *

Have you ever used tobacco/nicotine? *

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?

Why were you prescribed medical marijuana?

How often do you use marijuana?

How do you use marijuana?

Smoke
Vape
Edibles
Pills
Sprays or Topical
Tinctures

Check all that apply as rules may vary with some companies.

How much life insurance do you need? *

How long do you need coverage for? *

How tall are you? *

How much do you weigh? *

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?

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?

Have you ever had any FAA violations?

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?

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

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?

Has any treatment/surgery been recommended that you have not completed yet?

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?

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?

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?

What are your most recent liver function test results

AST

ALT

ALP

Bilirubin

GGTP

Have you had an ultrasound or liver biopsy completed?

Was there any indication of:

Inflammation
Fibrosis
Cirrhosis
Fatty Liver

Do you drink alcohol?

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?

Please provide dates of hospitalization(s) and reason for visit.

Have you received disability benefits in the past 5 years?

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?

Have you had any mental deterioration or personality changes from epilepsy?

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?

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?

How often do you attend meetings and/or therapy?

If no, why not?

Have you had any relapses?

What were the approximate dates of relapse, and subsequent treatment dates?

Do you take any medications?

Medication Details

Name *

First

Last

Email *

Phone *