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A CHOICE OF COMPANIES
TO ENSURE THE BEST
COVERAGE AT A
COMPETITIVE
PRICE

Client Name:
Home Phone:
Email:
Name:
Birthdate:
Gender:	Male: Female:
Health Class [Chart]:
Face Amount Desired
Medical Problems:
Medications & Dosage:
Insured #2
Name:
Birthdate:
Gender:	Male: Female:
Health Class [Chart]:
Face Amount Desired
Medical Problems:
Medications & Dosage:

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Select Your Health Class Based on the Criteria Below
Carefully review the information below to ensure you get an accurate quote.

Preferred Plus Non-Tobacco	Preferred Non-Tobacco	Standard Plus Non-Tobacco	Standard Non-Tobacco
Tobacco Use: None in the last 5 years Aviation or Hazardous Avovation: No Cholesterol: If HDL <4.5, 205If HDL <4.0, 240 Blood Pressure: 0 - 60:140/8561+:150/85 and no Blood Pressure Treatment MVR: 1 violation in 3 yearsNo DUI, Reckless driving or Revocation/Suspension in last 5 years. Family History: No Cardiovascular disease prior to age 60 (Parents Only). Personal History: No cancer or ratable impairment. Select Preferred Plus	Tobacco Use: None in the last 3 years Aviation or Hazardous Avocation: No Cholesterol: If HDL <5.5,235 If HDL <5.0, 260 Blood Pressure: 0 - 60: 145/88 61+: 155/88Or Pref. Plus BP w/ Treatment MVR: 2 violations in 3 yearsNo DUI, Reckless driving or Revocation/Suspension in last 5 years. Family History: No Cardiovascular death prior to age 60.(Parents Only) Personal History: No cancer or ratable impairment. Select Preferred	Tobacco Use: None in the last 2 years Aviation or Hazardous Avocation: With flat extra Cholesterol: If HDL <6.5,250 If HDL <6.0, 280 Blood Pressure: 0 - 60: 150/92 61+: 160/92Or Pref. Plus BP w/ Treatment MVR: 2 violations in 3 yearsNo DUI, Reckless driving or Revocation/Suspension in last 5 years. Family History: No Cardiovascular death prior to age 60.(Parents Only) Personal History: No cancer or ratable impairment. Select Standard Plus Non-Tobacco	Tobacco Use: None in the last year Aviation or Hazardous Avocation: With flat extra C holesterol: If HDL > 6.5, 250 If HDL > 6.0, 280 Blood Pressure: 0 - 60: 150/92 61+: 160/92Or Pref. NT BP w/ Treatment MVR: 3 violations in 3 yearsNo DUI, Reckless driving or Revocation/Suspension in last 2 years. Select Standard Non-Tobacco
Preferred Tobacco	Standard Tobacco
Aviation or Hazardous Avocation: No Cholesterol: If HDL <5.5, 235 If HDL <5.0, 260 Blood Pressure: 0-60:145/88 61+:155/88 or Pref. Plus BP reading with Treatment MVR: 2 violations in 3 years.No DUI, Reckless driving or Revocation/Suspension in last 5 years. Family History: No cardiovascular death prior to age 60. (Parents only) Personal History: No cancer or ratable impairment Select Preferred Tobacco	Aviation or Hazardous Avocation: With flat extra Cholesterol: If HDL > 5.5, 235If HDL > 5.0, 260 Blood Pressure: 0-60: 145/88 61+: 155/88 or Pref. NT BP reading with Treatment MVR: 3 violations in 3 years.No DUI, Reckless driving or Revocation/Suspension in last 2 years Select Standard Tobacco

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