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Your Date of Birth
Jan
Feb
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Dec
01
02
03
04
05
06
07
08
09
10
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12
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1910
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1930
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1955
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1962
1963
1964
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1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
Your Gender
Male
Female
Your Height
4
5
6
7
ft
0
1
2
3
4
5
6
7
8
9
10
11
in Weight
lbs
Do you use Tobacco or Nicotine?
Never
None in the last 5 years
None in the last 4 years
None in the last 3 years
None in the last 2 years
None in the last year
Current user
If so, how often?
Cigarettes, less than 1 pack a day
Cigarettes, more than 1 pack a day
Cigar or Pipe daily
Cigar or Pipe, once a week
Cigar or Pipe, once a month
Cigar or Pipe, 12 or less a year
Cigar or Pipe, more than 12 per year
Nicotine patch or gum
Chew or snuff
N/A
Coverage Amount
$500,000
$50,000
$75,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
$550,000
$600,000
$650,000
$700,000
$750,000
$800,000
$850,000
$900,000
$950,000
$1,000,000
$1,100,000
$1,200,000
$1,300,000
$1,400,000
$1,500,000
$1,600,000
$1,700,000
$1,800,000
$1,900,000
$2,000,000
$2,250,000
$2,500,000
$2,750,000
$3,000,000
$3,250,000
$3,500,000
$3,750,000
$4,000,000
$4,250,000
$4,500,000
$4,750,000
$5,000,000
Guaranteed Term
All Products
5 Years
10 Years
15 Years
20 Years
25 Years
30 Years
Your Health Class
Best Class
Preferred
Standard Plus
Standard
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