Complete our online form below for yourself and/or other family members to receive a no-obligation quote tailored to each individuals specific age, health, and coverage needs.

Michigan residents only.

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Underwriting Questionnaire

MM slash DD slash YYYY
Gender
Have you used any tobacco products?

Have you been treated or sought treatment for:

drug or alcohol abuse?
moderate/severe asthma, chronic bronchitis, Crohns, diabetes, epilepsy(seizure w/in 2yrs), gastric/peptic ulcer(treated w/in 2yrs),chronic kidney/liver disease, mental illness, multiple sclerosis, ulcerative colitis?
for depression within the past 2 years?
cardiovascular heart disease, chronic obstructive pulmonary disease, emphysema, stroke(inc. TIA), vascular disease?
Have you or do you plan Gastric by-pass surgery, or have you lost or gained more than 10 pounds in the past two years?
Have you lost a parent or sibling to an early death due to heart attack, stroke, or cancer?
Is your blood pressure normal?
Is your cholesterol level normal?
In past 5 years have you had 3 or more traffic violations or been convicted of D.U.I. (Driving Under the Influence)?
Any hazardous occupation/hobbies?
Plans to travel to underdeveloped or unstable countries?

I am interested in:

Duration of plan

Completing a request for an illustration (quotation) does not guarantee that a policy will be issued or will it obligate you to accept a policy.

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