Start Your Application Step 1 of 3 33% CompanyThis field is for validation purposes and should be left unchanged. Step 1: Verify Your Details Please review the information below for accuracy. If you need to make changes, you can edit the fields directly. Once everything looks correct, click “Next” at the bottom to begin the medical pre-qualification questions. First Name(Required)Last Name(Required)Gender(Required) Male Female Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN (Last 4 Digits Only)(Required)Which type of insurance product are you applying for?(Required)Term LifeFinal ExpenseDividend Whole LifeIndexed Universal Life (IUL)Guaranteed Universal Life (GUL)Other/I Don't KnowSelect Your Term(Required)10 Year15 Year20 Year25 Year30 YearSelect Your Coverage Amount(Required)$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000$1,500,000$2,000,000$2,500,000$3,000,000$3,500,000$4,000,000$4,500,000$5,000,000$5,500,000$6,000,000$6,500,000$7,000,000$7,500,000$8,000,000$8,500,000$9,000,000$9,500,000$10,000,000$10,000,000+What is the amount of coverage you're looking for?(Required)How much Final Expense coverage are you looking for?(Required)$5,000$6,000$7,000$8,000$9,000$10,000$11,000$12,000$13,000$14,000$15,000$16,000$17,000$18,000$19,000$20,000$21,000$22,000$23,000$24,000$25,000$26,000$27,000$28,000$29,000$30,000$30,000+What is your monthly budget for this coverage?(Required)What is your primary goal for this policy? Anything else we should know?(Required)This will help us design the policy better, but is not required to answer.Is the proposed insured a US citizen or permanent resident?(Required) Yes No Please explain your legal status. Include your country of current citizenship, type of visa (if applicable), date entered the United States, and information on any pending applications.(Required)Do you have a US bank account?(Required) Yes No Full Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Height (feet)(Required)Height (inches)(Required)Weight (Lbs)(Required)Tobacco and Nicotine Use:(Required) Never Quit less than a year ago Quit more than a year ago Occasional Cigar Use Currently Use Tobacco Products Marijuana Use:(Required) Currently (within the last year) Formerly (over one year ago) Never How often per week do you use Marijuana?(Required)Once Weekly2 to 6 times/weekDailyMultiple Times a DayDo you smoke or use edibles?(Required) Smoke Edibles Both Have you ever had issues related to use, such as DUI, job loss, legal problems, etc?(Required) Yes No Have you disclosed this use on life insurance applications before?(Required) Yes No I haven't applied for life insurance while actively using marijuana. Medical History ProfileTo speed up this process, please select any categories below where you have a past or current medical history. We will only ask for details on the specific areas you check.Does the proposed insured have a history of medical conditions involving any of the following? (Check all that apply) ADD/ADHD Has the proposed insured been treated for this condition in the past 12 months?(Required) Yes No Approximate Year of Diagnosis for ADD/ADHD?(Required)How many times has the proposed insured been to the hospital for ADD/ADHD?(Required)012345678910+List All Medications Taken for ADD/ADHD(Required)Alcohol or Drug Abuse? Alcohol or Drug Abuse Current or Past?(Required) Current Past, over 2 years What type of treatment for Drug/Alcohol abuse?(Required)Date of Last Use(Required)Less than 6 months6-12 months1-2 years2 to 3 years3 to 4 years4 to 9 years10 years or moreAnxiety Anxiety How does the Proposed Insured describe their condition?(Required) Mild or Situational Moderate Severe How many times has the Proposed Insured been admitted to the hospital for this condition?(Required)012345678910+List all medications taken for anxiety:(Required)Asthma Asthma In a typical year, how many asthma attacks does the Proposed Insured typically have?(Required) None 1 to 6 7 to 12 13 or more In the last year, how many times has the Proposed Insured been admitted (for one night or more) to hospital due to an asthma attack?(Required)012345678910+When did you last have symptoms of asthma?(Required) MM slash DD slash YYYY How does the proposed insured treat their condition?(Required) Occasionally Single Medication Two Medications Three or More Medications Atrial Fibrillation Atrial Fibrillation Is the Proposed Insured's atrial fibrillation triggered by alcohol use?(Required) Yes No How long ago was the Proposed Insured's last episode of atrial fibrillation?(Required)Less than 1 year1 to 3 years4 to 9 years10 or more yearsWhat medications does the proposed insured take for atrial fibrillation?(Required)Bipolar Bipolar How long ago was the Proposed Insured diagnosed with bipolar disorder?(Required) Less than 6 Months 6 to 12 Months 1 to 4 Years 5 years or More How many times has the Proposed Insured been admitted to the hospital for this condition?(Required)012345678910+Severity?(Required) Mild Moderate Severe List all medications the proposed insured is taking for bipolar disorder:(Required)Blood Pressure Blood Pressure What's the proposed insured's last systolic (top number) blood pressure reading?(Required)120 or lower121-125126-130131-135136-140141-145146-150151-155156-160161-165166-170171-175176-180181-185186-190191-195196-200201 or higherWhat's the proposed insured's last diastolic (bottom number) blood pressure reading?(Required)80 or lower81-8586-9091-9596-100101-105106-110111-115116-120121 or higherList all medications the proposed insured is taking for blood pressure:(Required)Cancer or Tumors Cancer or Tumors How long ago was the Proposed Insured last diagnosed with cancer/tumors?(Required) Less than 1 year 1 to 3 years 4 to 5 years 6 to 9 years 10 or more years Please provide additional details including, type of cancer/tumor, date(s) of diagnosis, what stage of cancer/tumor, how was it treated, and any lingering effects.(Required)Example: "Diagnosed with breast cancer in 2009, stage one. Treated with a month of chemotherapy. No reoccurrences or complications since."Cholesterol Cholesterol Last cholesterol reading:(Required)Less than 200200 to 240241 or higherList all medications taken for cholesterol:(Required)Colitis/Crohn's disease Colitis/Crohn's disease How long ago was the Proposed Insured diagnosed with this disorder?(Required)Less than 1 year1 to 3 years4 to 9 years10 or more yearsSymptom frequency?(Required)Chronic (all of the time)Acute (sudden flare-ups)When was the last colonoscopy?(Required)Less than a year1 to 3 years4 to 9 years10 or more yearsList all medications taken for colitis/crohns:(Required)Depression Depression How long ago was the Proposed Insured diagnosed with depression?(Required)Less than 6 months6 to 12 months1 to 4 years5 years or moreHow many times has the Proposed Insured been admitted to the hospital for this condition?(Required)012345678910+List all medications taken for depression:(Required)Diabetes or Blood Sugar Diabetes or Blood Sugar What type of diabetes?(Required)Type 1Type 2 or PrediabetesGestationalLADA or Other Blood Sugar IssueDoes the proposed insured have hypoglycemia?(Required) Yes No Year of diagnosis?(Required)Last A1C reading?(Required)I have hypoglycemia.6.5 or below6.6 to 7.07.1 to 7.57.6 to 8.08.1 to 8.58.6 to 9.09.1 to 9.59.6 to 10.010.1 or higherWhat medications for diabetes/blood sugar?(Required)Any complications? Type N/A if no complications. If you Neuropathy, Amputations, Vision Problems or other complications from diabetes, list below, along with date of diagnosis and severity:(Required)GERD (Gastroesophageal Reflux Disease) GERD List any medication for GERD. If no medication, write 'none'.(Required)Heart or Circulatory System Heart or Circulatory System Do any of these apply to the Proposed Insured?(Required) Heart Attack Angioplasty Bypass Valve Surgery More than one of the Above None of the Above Do any of these apply to the Proposed Insured?(Required) Placed on a Defibrillator Inserted a Pacemaker Use of Oxygen More than one of the Above None of the Above Provide all issues related to heart or circulatory system, including: Type of condition, date diagnosed, and treatment.(Required)Example: "I was diagnosed with a faulty heart valve in 2015. It was replaced with a pig valve. I don't currently have any issues with it."What medications are taken for this/these heart or circulatory issues?(Required)Immune System (Includes Autoimmune Disorders) Immune System (Includes Autoimmune Disorders) Do any of the following conditions apply?(Required) Rheumatoid Arthritis Psoriatic Arthritis Discoid Lupus Systemic Lupus Other What was the year of diagnosis, and what is the severity? If you listed "other" on the previous question or have more than one autoimmune condition, list all conditions, year of diagnosis, and severity.(Required)What medications are taken for this condition?(Required)What is the Proposed Insured's functionality with the condition?(Required) Fully Active Sedentary Walker/Cane Wheelchair Kidney or Liver Kidney or Liver Is the proposed insured currently on dialysis?(Required) Yes No List the kidney and/or liver diagnosis. Include year of diagnosis, severity of the condition, and all medications and/or treatments for the condition(s).(Required)Neurological or Nervous System (Includes Neuropathy of all kinds) Neurological or Nervous System List the neurological or nervous system diagnosis. Include year diagnosed, severity of the condition, and all medications and/or treatments for the condition(s).(Required)PTSD PTSD How many times has the Proposed Insured been admitted to the hospital for this condition?(Required)012345678910+Is the Proposed Insured currently receiving any government benefits, allowance or credits due to PTSD, or have they retired early due to this condition?(Required) Yes No In total, how many months has the proposed insured had off due to this condition in the last year?(Required)0123456789101112What prescriptions does the proposed insured take for PTSD?(Required)Self Harm Self Harm Sleep Apnea Sleep Apnea Approximate Year of Diagnosis?(Required)What is the prescribed course of treatment?(Required)Example Answer: Sleep Apnea (wear cpap every night)Other Respiratory Issues (Includes COPD) Other Respiratory Issues (Includes COPD) Does the proposed insured have COPD?(Required) Yes No Does the proposed insured require oxygen?(Required) Yes No What is the respiratory condition? Also include date of diagnosis, severity, treatment, and any other important details:(Required)Stroke or TIA Stroke or TIA Advise which applies, as well as the date(s), treatments, and any complications:(Required)Proposed insured has a hospitalization in the last 5 years I haven't listed. Proposed insured has a hospitalization in the last 5 years that hasn't been listed. Explain. Provide date and reason for hospitalization.(Required)Proposed insured has a medical Issue or take a prescription that hasn't been listed. Proposed insured has a medical Issue or take a prescription that hasn't been listed. List the other diagnosis or prescription drug we haven't covered. Include year of diagnosis, severity of the condition, and all medications and/or treatments for the condition(s).(Required)None of The Above(Required) Proposed insured does not have any medical problems and have not been prescribed, nor take any prescription drugs. Family, Lifestyle & BackgroundYou are almost done! To qualify you for the best possible rate class, carriers may look beyond your current health. Please answer the following questions regarding your Family History, Occupation, and Driving Record. These details help us match you with the carrier most likely to offer you the lowest premium.My occupation is:(Required)My Annual Income Is:(Required)I am looking for life insurance coverage for myself or someone else because:(Required)Section BreakPlease check the box if the statement is TRUE. The Proposed Insured's biological mother or father have been diagnosed with Heart Disease, Cerebrovascular Disease, Cancer or Diabetes at or before age 70. Which parent (or both) and which condition(s)?(Required)The Proposed Insured's biological sibling(s) have been diagnosed with Heart Disease, Cerebrovascular Disease, Cancer or Diabetes at or before age 50. The Proposed Insured's biological sibling(s) have been diagnosed with Heart Disease, Cerebrovascular Disease, Cancer or Diabetes at or before age 50. Which sibling(s) and which condition(s)?(Required)The proposed insured has been advised by a medical professional that they need tests, surgery, or hospitalization that have not been received or completed. The proposed insured has been advised by a medical professional that they need tests, surgery, or hospitalization that have not been received or completed. Explain:(Required)The Proposed Insured has difficulty with activities of daily living such as: bathing, dressing, eating, toileting, getting in and out of a chair or bed, control of bowel/bladder problems, uses a wheelchair, electric scooter, or is receiving or has been advised by a medical professional to receive care in a nursing home, hospice, or home health care. The Proposed Insured has difficulty with activities of daily living such as: bathing, dressing, eating, toileting, getting in and out of a chair or bed, control of bowel/bladder problems, uses a wheelchair, electric scooter, or is receiving or has been advised by a medical professional to receive care in a nursing home, hospice, or home health care. Explain:(Required)The Proposed Insured has received treatment or has been diagnosed for any of the following: Parkinsons, Multiple Sclerosis, HIV, AIDS, Chronic Pancreatitis, Sickle Cell Anemia, Dementia, Alzheimers, Hepatitis C, Organ Transplant, ALS, or Cirrhosis of the Liver. The Proposed Insured has received treatment or has been diagnosed for any of the following: Parkinsons, Multiple Sclerosis, HIV, AIDS, Chronic Pancreatitis, Sickle Cell Anemia, Dementia, Alzheimers, Hepatitis C, Organ Transplant, ALS, or Cirrhosis of the Liver. Provide which condition(s), when you were diagnosed, current and former treatment, severity of condition, and any other details you deem relevant:(Required)The proposed insured is currently on disability. (VA, Social Security, etc.) The proposed insured is currently on disability. (VA, Social Security, etc.) Provide the year you went on disability, why you went on disability, and your rating, if applicable.(Required)The proposed insured has travelled outside the United States in the last 2 years, or has plans to do so in the next 12 months. The proposed insured has travelled outside the United States in the last 2 years, or has plans to do so in the next 12 months. Explain(Required)The proposed insured has filed for bankruptcy in the last 5 years. The proposed insured has filed for bankruptcy in the last 5 years. The proposed insured engages in high risk activities, such as racing, scuba diving, hang gliding, mountain climbing, skydiving, or parachuting. The proposed insured engages in high risk activities, such as racing, scuba diving, hang gliding, mountain climbing, skydiving, or parachuting. Explain:(Required)The proposed insured currently pilots an aircraft or expects to pilot an aircraft within the next 12 months. The proposed insured currently pilots an aircraft or expects to pilot an aircraft within the next 12 months. Does the proposed insured hold a current instrument rating?(Required) Yes No How many hours of instrument flight time has the proposed insured logged?(Required)Please enter a number greater than or equal to 0.How many hours of night flying has the proposed insured logged?(Required)Please enter a number greater than or equal to 0.How many years has the proposed insured been a licensed pilot?(Required)Please enter a number greater than or equal to 0.How many total hours has the proposed insured logged as pilot in command?(Required)Please enter a number greater than or equal to 0.How many flight hours does the proposed insured average per month?(Required)Please enter a number greater than or equal to 0.List the proposed insured's current pilot certificates, ratings, and relevant aviation training.(Required)Has the proposed insured ever had an aviation accident, incident, or violation?(Required) Yes No Describe each aviation accident, incident, or violation, including the date and outcome.(Required)List the make and model of every aircraft the proposed insured expects to fly.(Required)How many total flight hours does the proposed insured expect to log during the next 12 months?(Required)Please enter a number greater than or equal to 0.In the last 10 years, the Proposed Insured had a DUI or DWI. In the last 10 years, the Proposed Insured had a DUI or DWI. How long ago was the Proposed Insured charged with the offense?(Required)Less than 6 months6-12 months1 to 2 years2 to 3 years3 to 4 years4 to 7 years8 years or moreThe Proposed Insured had two or more moving violations in the past 2 years. The Proposed Insured had two or more moving violations in the past 2 years. How many?(Required)2345678910+The Proposed Insured had their license suspended or revoked in the past. The Proposed Insured had their license suspended or revoked in the past. How long ago?(Required)CurrentlyLess than 12 months1 to 2 years2 to 3 years4 to 5 years5 to 6 years6 to 7 years8 years or moreHas the Proposed Insured been convicted of, or are they currently being charged with, a felony? Or currently on parole or probation? The Proposed Insured has been convicted of, or currently being charged with a felony, or is currently on parole or probation. Explain:(Required)The purpose of this coverage is business related (business solutions examples of buy-sell, key-person, executive bonus, etc., or personal insurance on business owners, key employees, and their family members). The purpose of this coverage is business related (business solutions examples of buy-sell, key-person, executive bonus, etc., or personal insurance on business owners, key employees, and their family members). Explain:(Required)Section BreakAny other details you would like us to know:Final Disclosure and Consent(Required) By signing below, I certify that the answers provided in this application are true, complete, and correctly recorded to the best of my knowledge and belief. I understand that any misrepresentation or omission of material fact may result in the denial of a claim or cancellation of the policy. By checking this box, I agree to receive calls and text messages, including marketing and informational messages, from Insurance By Heroes at 855-434-3500 or 443-214-3500 about my insurance quote, application, policy, or appointment, even if my number is listed on a state, federal, internal, or any other Do Not Call list. Message frequency varies. Message and data rates may apply. Reply STOP to opt out of texts and HELP for help. Consent is not a condition of purchase. We will not share mobile information with third parties or affiliates for promotional or marketing purposes. See Terms and Conditions and Privacy Policy.Signature(Required)
