image1

Health Insurance
Health saving accounts
Dental insurance
Short-term health insurance
Student health insurance

image2

Life Insurance
Receive lowest quotes
Compare carriers
Fast, easy application
Friendly help available

image3

Medicare Supplement
Compare carriers
Fast, easy application
Friendly help available

image4

CONTACT US
Phone Numbers
1-800-739-4700
1-847-626-7120

Life Insurance

Health & Retirement makes it possible to quickly compare the cost, features, and financial strength of hundreds of life insurance products! As a result, our clients typically save up to 70%.

US Residents Only.

 

*

Required information

Title

*

First Name

*

Last Name

*

In which state do you live?

*


Not available in SD or outside the US.

Date of birth

*

 mm   dd   yyyy 

Gender

*

Height

*

 ft.   in. 

Weight

*

 lbs. 

Have you ever had or been treated for any of the following conditions?

*

No
Blood Pressure
Cancer
Cholesterol
Heart Problem
Depression, Anxiety
Diabetes
Alcohol or Substance Abuse
Asthma
Other significant issues

Do you currently have a life insurance policy?

*

Yes   No  

What is the coverage on your existing life insurance policy?

*


Numerals only. No punctuation. (e.g. 100000)

Are you planning to replace this coverage?

*

Yes   No  

Experts typically recommend that you purchase coverage of 7-10 times the amount of annual income you need to replace.

Amount of coverage you wish to obtain:

*

Alternate amount:

 

Desired duration of policy (years):

*

To offer the right rate, insurance companies consider your family's health history an important factor in determining your final price.

If you are adopted, check here and skip the next set of questions.

 

 

Before they turned 70 , did any of your parents or siblings have incidents of or die from heart disease, cancer, stroke, or diabetes?

*

No
Yes, the following occurred:

Father:

 

Cancer
Heart
Diabetes
Stroke

Mother:

 

Cancer
Heart
Diabetes
Stroke

Siblings:

 

Cancer
Heart
Diabetes
Stroke

Your lifestyle may include risks that an insurance company must take into account.

How many tickets have you received for moving violations in the last 3 years?

*

How many tickets have you received for moving violations in the last 5 years?

*

Have you had any DUI citations?

*

Have you smoked cigarettes in the last 5 years?

*

Have you used any other forms of tobacco or nicotine in the last 5 years?

*

In the past 2 years, did you live or travel outside the U.S. or Canada?

*

Yes   No  

In the next 2 years, do you have any plans to live or travel outside the U.S. or Canada?

*

Yes   No  

Have you ever flown in an aircraft in any capacity other than a passenger?

*

Yes   No  

Have you done any SCUBA diving in the last 3 years ?

*

Yes   No  

Do you engage in any hazardous sports or activities?

*

You're almost done. Thank you for taking the time to answer all of our questions. Now we just need your contact information, so we can be sure you get your quote as quickly as possible.

Street

*

City

*

State

*

Zip

*

Office Phone #

 - 

 - 

 ext. 

Home Phone #

*

 - 

 - 

E-Mail address:

*