Annuity & Term Life Center
Comparative Term Life Insurance Quote
Coverage Amount	$100,000.00 $125,000.00 $150,000.00 $175,000.00 $200,000.00 $225,000.00 $250,000.00 $275,000.00 $300,000.00 $325,000.00 $350,000.00 $375,000.00 $400,000.00 $425,000.00 $450,000.00 $475,000.00 $500,000.00 $600,000.00 $700,000.00 $800,000.00 $900,000.00 $1,000,000.00 $1,500,000.00 $2,000,000.00 $2,500,000.00 $3,000,000.00 $3,500,000.00 $4,000,000.00 $4,500,000.00 $5,000,000.00 $6,000,000.00 $7,000,000.00 $8,000,000.00 $9,000,000.00
State of Residence	Alabama Alaska Arizona Arkansas California Colorado Connecticut DC Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Gender	Male Female
Date of Birth   (You must be at least 21 years old)	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924
Height	4 5 6 ft 0 1 2 3 4 5 6 7 8 9 10 11 in
Weight	Pounds
Desired Term	5 Years 10 Years 15 Years 20 Years 30 Years
Have you used cigarettes?	No, Never Yes Not within the past year Not within the past 2 years Not within the past 3 years Not within the past 5 years Not within the past 10 years
Have you used any tobacco products?   (Pipes, cigars, chewing tobacco, dip, snuff, nicotine patches or gum)	No, Never Yes Not within the past year Not within the past 2 years Not within the past 3 years Not within the past 5 years Not within the past 10 years
The "Comparative Quote" provides you with a quote based on a minimal amounts of information. The quote provided is not necessarly the price you will pay for your term life insurance. Medical information that will be asked when you fill out and application is not contained within the "Quick Quote". We have created an more extensive "Quote Request Form" below which closely resembles the actual questions that will be asked when you fill out an application for life insurance. By taking the time to answers these questions the quote provided will be much closer to the actual premium you will be paying.
Comprehensive Term Life Insurance Quote
Blood Pressure
I have been treated for High Blood Pressure	Select Yes No
My blood pressure is   (Leave blank if you don't know)	Systolic      Diastolic
Cholesterol
I have been treated for High Cholesterol	Select Yes No
My HDL Ratio and Cholesterol is   (Leave blank if you don't know)	HDL Ratio      Cholesterol
Family History
Have any of your immediate family members had   any of the following:   heart attack, stroke, diabetes, cancer, or   kidney disease	Select Yes No
Hazardous Activities
Are you a pilot?	Select No Yes, Private Pilot Yes, Commercial Pilot Yes, Student   If yes, with hours
Are you Active Military Duty?	Select Yes No
Do you have a Hazardous Occupation?	Select Yes No
A Hazardous Hobby or Avocation?	Select Yes No
Do you intend to travel to politically unstable   countries?	Select Yes No
Driving History
Any driving moving violations?	Select No Yes, 2 or more within the past year Yes, 2 or more within the past 2 years Yes, 3 or more within the past 3 years Yes, 2 within the past 3 years Yes, less than 2 in the past 3 years
Have you ever been found guilty of reckless   driving, driving under the influence, driving   while intoxicated, or have had your license   revoced or suspended?	Select No Yes, within the past year Yes, within the past 2 years Yes, within the past 3 years Yes, within the past 5 years Yes, within the past 10 years
Residency
Citizenship Status	I am a U. S. Citizen Permanent Resident or hold a Green Card Neither
Medical Conditions Have you ever been treated for any of the following conditions? If "yes" please check
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