Desired Coverage:  

Name:

Occupation:

Mailing Address:

City:   State: Rhode Island Connecticut Alabama Alaska Arizona Arkansas California Colorado 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 South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Phone:

E-mail:

Gender   Male Female    Date of Birth:

Height:     Weight:

Please answer the following questions to help us better estimate your premium. Actual premiums will vary based on the results of our underwriting process. This is not an application for insurance and will not be used as part of the underwriting process.

Have you ever been convicted of a DWI (Driving While Intoxicated) or DUI (Driving Under the Influence)?	No Yes - within the last 3 years Yes - within the last 5 years Yes - within the last 7 years Yes - over 7 years ago
Have you had more than two moving violations in the last two years?	yes no
Have you ever had a problem with or been treated for drug or alcohol abuse?	No Yes - within the last 5 years Yes - within the last 7 years Yes - over 7 years ago
When was the last time you used tobacco or nicotine products?	Never Used Used within the last 5 years Used within the last 7 years Used within the last year Current User
Do you engage in any hazardous activities or sports?	yes no
Do you currently fly or intend to fly as a private pilot?	yes no
Have you ever been treated for or been told that you have high cholesterol?	yes no
Have you ever been treated for or been told that you have high blood pressure?	yes no

Please indicate each medical condition that applies to or has applied to you:

Asthma	Anxiety	Anemia	Allergies
Sleep Apnea	Hypothyroid	Reflux	Epilepsy
Chronic bronchitis Emphysema	Gastric / peptic ulcer	Hypertension	Depression (last two years)
Mental illness (treatment in last two years)	Diabetes	Cancer	Heart Disease
Please check this box if you have family history of cardiovascular deaths or multiple cancer deaths prior to age 60 in parents or siblings.