Potential Insured Information

First Name *

Last Name *

Phone *

Sex/Gender *

Your Age

Used tobacco in the past 2 years? *

Height *

Weight *

City *

State *

Postal code *

Even though this life insurance product doesn't require a medical exam, it does require answering some basic health history questions with yes or no responses. Please answer the following questions to check your eligibility.

Within the last 12 months used, any of the following: walker, wheelchair, electric scooter, supplemental oxygen, or catheter? *

YES

In the past 10 years, have you used heroin, morphine, other unprescribed narcotics, ecstasy, opium derivatives, marijuana for medical purposes, cocaine, crack, barbiturates, amphetamines, methamphetamines, or hallucinogens or any other illegal, restricted or controlled substances; or been treated or been advised by a licensed member of the medical profession to seek treatment for the intake of any drug? *

YES

In the past 10 years, have you used alcohol to a degree that required treatment or was advised to limit or discontinue its use by a licensed member of the medical profession? *

YES

Have you ever been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Stent Placement, Angina (chest pain), Valvular Heart Disease, Cerebrovascular Disease, Cardiomyopathy, Congestive Heart Failure, Congenital Heart Disease, Stroke, Transient Ischemic Attack(TIA, Mini Stroke), abnormal heart rhythm, had placement of a Pacemaker or Defibrillator, Cerebral, Aortic or Thoracic Aneurysm, or Abdominal Aortic Aneurysm? *

YES

Have you ever been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Chronic Lung Disease (except mild Asthma), including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, Sarcoidosis, Pulmonary Hypertension, or Cystic Fibrosis? *

YES

Have you ever been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Major Depression, Bipolar Disorder, Schizophrenia, Alzheimer’s Disease, Dementia, Memory Loss, Down Syndrome, Autism, mental incapacity, suicide attempt, eating disorders, Chronic Depression, or any other nervous disorder? *

YES

Have you ever been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Chronic Kidney Disease, End-Stage Renal Disease, Renal Insufficiency, or any condition within the last 5 years that required dialysis? *

YES

Have you ever been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Parkinson’s disease, Sickle Cell Anemia, Pernicious Anemia, Thalassemia, clotting disorders, or other disorders of the blood, Lou Gehrig’s Disease (ALS), Muscular Dystrophy, Demyelinating Disease including Multiple Sclerosis, Huntington’s Disease, Hydrocephalus, Cerebral Palsy, Quadriplegia, or Paraplegia? *

YES

Have you ever been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Liver Disease, Liver Failure, Cirrhosis or any form of Hepatitis (excluding Hepatitis A from which you have fully recovered)? *

YES

Have you ever been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Cancer, Leukemia, Melanoma, any tumor (benign or malignant) of the brain, or any other internal cancer (except basal cell cancer)? *

YES

Have you ever been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Connective tissue or autoimmune disorder including Rheumatoid, debilitating or disabling arthritis; chronic joint or disc disease, Systemic Lupus, or Scleroderma? *

YES

Have you ever been the recipient of an organ transplant? *

YES

Have you ever been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Ulcerative Colitis or Crohn’s Disease? *

YES

Have you been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Epilepsy or Seizure Disorder which has been diagnosed within the past 6 months, has caused you to be hospitalized within the last 12 months, or do you have any driving restriction due to Epilepsy or Seizure Disorder? *

YES

Have you been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Sleep Apnea, diagnosed within the last 6 months, or for which you are not being treated (CPap or BiPap)? *

YES

Have you been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Mild or Situational Depression or Anxiety, diagnosed within the last 6 months, or for which you have been hospitalized? *

YES

Have you been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Psoriatic or other inflammatory Arthritis diagnosed within the last 6 months or for which you are undergoing infusion therapy or being prescribed by a licensed member of the medical profession biologics or take daily oral steroids? *

YES

Have you been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Any disease or disorder of the Bones or Muscles for which you have had surgery within the last 12 months and have not secured a release from a licensed member of the medical profession? *

YES

Have you been diagnosed with, or received care or treatment for, or consulted with or been advised by a licensed member of the medical profession to seek treatment for: Asthma for which you take daily oral steroid medications or for which, in the past 12 months, you have visited an Emergency Department, or been hospitalized? *

YES

Have you been prescribed narcotics by a licensed member of the medical profession to alleviate the pain of a chronic condition and have continued this medication for a period lasting more than 6 months? *

YES

In the past 2 years, other than for wellness visits, minor injuries, or illnesses for which a licensed member of the medical profession has deemed you fully recovered and requiring no further treatment or follow up, have you had: any labs, diagnostic testing, or procedure(s) completed with abnormal results, or results that require additional or follow-up diagnostic testing or treatment, or for which results are still pending? *

YES

In the past 2 years, other than for wellness visits, minor injuries, or illnesses for which a licensed member of the medical profession has deemed you fully recovered and requiring no further treatment or follow up, have you had: referral to another licensed member of the medical profession or facility for consultation or treatment that has not been completed, or consulted any licensed member of the medical profession not already identified for any reason? *

YES

Are you, at the time of completing this form, confined to any hospital or other medical or rehabilitation facility? *

YES

In the past 12 months, have you been recommended by a licensed member of the medical profession, but not yet completed, any treatment, surgery, or hospitalization? *

YES

How much can you comfortably afford now, 6 months and even 12 months from now for a monthly premium? (Please select one) *

Create Your Personal Reference Word: To help you remember this specific form that you completed when Ryan J. Kaiser calls, please type a memorable word or short phrase below that has meaning to you (example: your pet's name, favorite color, hobby, etc.) *

Final Step - Select Your Preferred Service Option

To ensure you receive the level of attention you deserve, please choose your preferred path forward:

Priority Service Path:

• Click "Submit" below

• You'll be IMMEDIATELY taken to Ryan's calendar on the next page

• Select your preferred 10-minute appointment time

• Receive immediate attention and rate analysis

• Get priority access to Ryan's best carrier options

Standard Service Path:

• Submit form without booking appointment

• Form reviewed between appointments/after hours

• Await for Ryan to reach out to me resulting in phone tag and making me feel like I'm being solicited (even though that's not his intention)

• May experience delayed response during busy periods

Please select your preferred service option below: *

PRIORITY SERVICE - Yes, this is important to me. I understand that after clicking "Submit," I'll be taken directly to Ryan's calendar to book my 10-minute appointment.

STANDARD SERVICE - I understand this isn't urgent for me. I prefer Ryan review my form when time permits and contact me later via text and/or phone call, though this may make me feel like I'm being solicited (even though I know that's not the intention).

Apply Now To See If You Qualify For Premium Life Protection At Preferred Rates

Complete The Form Below To Check Your Eligibility And Rates❗

Take your time to complete the below survey to see what you qualify for