What is your gender? *

Male

Female

Did you know that the only way to get day-one coverage is by having a licensed underwriter, trusted by the insurance carriers, submit the application?

Yes

Current Military Status? *

Discharged (other than dishonorable)

Retired

Reservist

Active Duty

The VA covers 10% of an average burial cost. Is this request to cover the remainder of your final expenses? *

Yes

Did you know that AARP, VA Life, Globe Life, Colonial Penn etc. make you pay premiums for 2 YEARS before the coverage kicks in? *

Yes

In the past 24 months, have you been diagnosed or treated for any of the chronic or debilitating illness? (Cancer, Parkinsons, Heart Attack, Stroke etc.)

Yes

Current Disability Rating? *

0% - 30%

31% - 60%

61% - 99%

100%

Are you a smoker? *

Smoker

Non - Smoker

Date Of Birth

Would you be more comfortable working with a proven, veteran endorsed team rather than a random salesperson? *

Yes

LOOKING GREAT!

Complete the information below for your Day-One Coverage quote today! Every day without coverage is a risk!

First Name *

Last Name *

Email *

Phone *

State *

You can book a call with Matt, Arianna & Joseph on the next page.

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from Vet Life Coverage. Message frequency varies. Message & data rates may apply. Text HELP to +1 866-985-5996 for assistance. You can reply STOP to unsubscribe at any time.