Pre-Qualification Rate Class
Daniel Ray 
CEO/Founder/Independent National Agent
Main: 855-380-3300 ext 4
Direct: 888-531-7955
Fax: 904-212-3020
National Producer Number: 16997242

Lisamarie Monaco-Ray
Co Founder/Independent National Agent
Main: 855-380-3300 ext 5
Direct: 888-659-7010
Fax: 904-212-3020
National Producer Number: 18776895


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Email *
Name (First, Middle Initial, Last) *
Email Address *
Gender
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Height *
Weight *
ZipCode *
Date of Birth *
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DD
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Phone No. *
Are you a legal resident of the United States? *
In the past 12 months, has the Proposed Insured used any form of tobacco or nicotine replacement therapy? *
UNDERWRITING
PART ONE
1. Is the Proposed Insured currently:
(A) bedridden or confined to any hospital, nursing home, long-term care facility or skilled nursing facility; or receiving or been advised to receive care in a nursing home, hospice care, or home health care? *
(B) requiring assistance with activities of daily living such as taking medications, bathing, dressing, eating, toileting, getting in and out of a chair or bed, or control of bowel or bladder problems? *
(C) requiring any of the following (other than for fractures, bone or joint surgery, including replacement): wheelchair, electric scooter, or oxygen equipment to assist breathing (excluding use for sleep apnea)? *
Please explain any yes answers above for (A), (B), (C).
2. Has the Proposed Insured ever been:
(a) diagnosed as having Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or Human Immunodeficiency Virus (HIV) Infection (symptomatic or asymptomatic) or been treated for AIDS, ARC, or HIV by a physician or health care provider? *
(b) diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for Alzheimer’s Disease, Dementia, Huntington’s Disease, Sickle Cell Anemia, Myelodysplastic Syndrome (MDS), Lou Gehrig's Disease (ALS), Quadriplegia, Paraplegia, Down’s Syndrome, mental incapacity, congestive heart failure, Cirrhosis, Metastatic Cancer or Recurrent Cancer of the same type? . *
If a "Yes" answer above, please explain the diagnosis and treatment.
(c) diagnosed with insulin shock, diabetic coma, or had an amputation due to diabetic complications or diagnosed with End-Stage Renal Disease or requiring dialysis?. *
(d) advised to receive or have received an organ or bone marrow transplant?. *
(e) diagnosed by a physician or health care provider as having a terminal medical condition that is expected to result in death within the next 12 months?. *
3. In the past 12 months, has the Proposed Insured been:
(a) advised by a physician to have a surgical operation, diagnostic testing other than for routine screening purposes or for those related to HIV/AIDS, treatment, hospitalization, or other procedure which has not been done or for which results are not known? *
(b) diagnosed by a physician or health care provider as having heart disease or heart surgery of any kind? *
4. In the past 2 years,
Has the Proposed Insured been diagnosed with, been treated for or advised by a physician or health care provider to receive treatment for any form of cancer (except basal or squamous cell skin cancer)? *
If a "Yes" answer above, please state type of cancer, month and year of diagnosis and if treatment is current and/or date of last treatment.
PART TWO
5. Has the Proposed Insured ever (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for:
(a) Diabetes before age 50 or diabetes at any age with complications of Retinopathy (eye), Nephropathy(kidney), Neuropathy (nerve) or Peripheral Vascular Disease (PVD or PAD)? *
(b) Hepatitis C? *
(c) Chronic Lung Disease, including Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis,Emphysema, or Sarcoidosis? *
Explanation of yes answers from (a), (b), (c) (if applicable)

6. In the past 4 years, has the Proposed Insured: (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for:
(a) Cancer, Leukemia, Melanoma or any other internal cancer (except basal or squamous cell skin cancer)? *
(b) Chronic Kidney Disease, Systemic Lupus or Scleroderma? *
(c) Bipolar Depression, Schizophrenia, Parkinson’s Disease or Multiple Sclerosis? *
Explanation of yes answers from a,b,c (if applicable)
7. In the past 2 years, has the Proposed Insured: (a) received care or treatment for, or (b) been advised by a physician or health care provider to seek treatment for:
(a) Coronary Artery Disease, Heart Attack, Coronary Artery Bypass Surgery, Angioplasty, Cardiomyopathy, irregular heart rhythm, or Valvular Heart Disease with surgical repair or replacement? *
(b) Have you ever had *
If applicable (How long since you had the Stroke/TIA)
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Explanation of yes answers from (a), (b), (if applicable)

8. In the past 2 years, has the Proposed Insured:
(a) been convicted of or currently awaiting trial for a felony?. *
(b) been treated for or advised to have treatment for alcohol or drug abuse or convicted more than once of reckless driving or driving under the influence of drugs or alcohol?. *
(c) used unlawful drugs in any form or abused or misused prescription drugs? *
Explanation of yes answers from a,b,c (if applicable)
9. In the past 2 years,
Has the Proposed Insured been hospitalized by a physician or healthcare provider for any mental or nervous disorder? *
10. In the past 12 months,
Has the Proposed Insured consulted a physician for chronic cough, unexplained weight loss greater than 10 pounds, fatigue or unexplained gastrointestinal bleeding?. *
**List Of Medications and Dosages** *
Amount Of Coverage You Looking For *
OTHER COVERAGE INFORMATION
1. Does the Proposed Insured have any pending applications or existing life insurance or annuity contracts with the company or any other company? *
2. Is the insurance applied for intended to replace or change any life insurance or annuity contract inforce with the company or any other company? *
Avoid Catostrophic Financial Burdens Due To Unforseen Circumstances
Do you have any Family History of: *
Would you like to hear about how you can get financial relief and a lump sum payout of $5000-$100000 upon diagnosis of any of the above health impairments *
Which Medicare Plan Do You Have *
If you have a Medicare Supplement, What Plan?
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How did you hear about us?   *
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