1. Health

Have You Used Any Tobacco, Nicotine or Marijuana Products In the last 12 Months? *

Yes

No

Tobacco type (Cigarette, Marijuana, Chew etc.?), Date of last use?, Frequency? *

Height *

Weight *

At What Age Were You Diagnosed With Diabetes? *

Have You Had Any Uncontrolled Diabetes in the Past 2 Years? *

Yes

No

Have you had any complications with your diabetes such as: Neuropathy, Retinopathy, Diabetic Coma, Insulin Shock, or Amputation due to complications of Diabetes? *

Yes

No

Are You Taking Any Insulin? *

Yes

No

Have you ever been diagnosed or received treatment for Lung Disease? COPD, Emphysema or Asthma? *

Yes

No

Which one? Are you receiving any treatment? *

Do you require the use of any oxygen or inhalers? *

Yes

No

Continuous Oxygen? Reason for use? *

Have you ever been diagnosed with Cancer? *

Yes

No

What type? How many years have you been treatment-free? *

Have you ever had any kidney insufficiency? Dialysis? Cirrhosis? Hepatitis? *

Yes

No

Which one? Years since diagnosis? Still have it or resolved? *

Have you ever had a Heart Attack, Bypass Surgery, Stent Surgery, Angina, Pacemaker, Defibrillator, Stroke, Seizure, Aneurism? *

Yes

No

Which one? Years since last one? *

Congestive Heart Failure? *

Yes

No

Date of diagnosis? Any Nitroglycerin tabs used or prescribed? *

Lupus? Multiple Sclerosis? Parkinson’s? Lou Gehrig’s? *

Yes

No

Which condition? *

Have you ever been diagnosed or received treatment for Depression, Bipolar Disorder, Schizophrenia, Alzheimer’s or Dementia? *

Yes

No

Which condition? Are you receiving any treatment? *

Have you ever been confined to a hospital, long term care, or nursing facility? *

Yes

No

When was the last time? Reason? *

2. Medications

Beyond the health questionnaire, the biggest determining factors of qualifying for burial insurance is what’s on your pharmacy report. As a licensed field underwriter, I know what medications burial insurance companies will and won’t take. Please list all medications and dosages here. If you have to, please go to your medicine cabinet and provide all the information below.

Please Provide A List of Your Current Medications, Dosages, and Years Taken (Ball Park is Fine) *

3. Financial

Almost done! Please answer these last 3 financial questions to determine which company will be the most suitable for your situation.

Do you have any active burial or life insurance inforce? *

Yes

No

If so: What Amount? What Company? Monthly Payments? Will this replace any coverage or add on to it?

Do you have a valid checking or savings account in the US?

Yes

No

Will anyone other than yourself be paying for this program? *

Yes

No

4. Submit

Submit the pre-qualification questionnaire