Build Your OWN Policy and Design Your Appropriate Coverage by Answering a Few Quick Questions.

You'll Then Receive Your Personalized Quote!!

Who will be your beneficiary? (check all that apply)

Spouse/Partner

Child(ren)

Grandchild(ren)

Other

Do you have at least $1 per day to set aside for this policy to protect your beneficiaries?

Yes

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Are you a legal United States citizen?

Yes

Do you have a checking account?

Yes

No, but I have a Direct Express card

In what state do you reside?

AL
AZ
FL
MA
MI
MS
NC
OH
PA
SC
TN
TX
VA
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Do you smoke or use nicotine products?

Yes

What is your birthday?

What is your height and weight?

Feet
Inches
Pounds

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Are there any health conditions you've been diagnosed with?

What prescribed medications are you currently taking (if any) with dosage?

How much dollar coverage (up to $50,000) would you like? (the amount paid to your beneficiaries)

Almost Done......

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First Name *

Last Name

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What is a good email to send you policy information?

Email *

For verification purposes, what is a good mobile number for you?

Phone *

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