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Life Insurance

Health & Retirement makes it possible to quickly compare the cost, features, and financial strength of hundreds of life insurance products! As a result, our clients typically save up to 70%.

US Residents Only.


* Required information

* Title

* First Name

* Last Name

* In which state do you live?

Not available in SD or outside the US.

* Date of birth

* Gender

* Height

 ft.   in. 

* Weight


* Have you ever had or been treated for any of the following conditions?

Blood Pressure Cancer Cholesterol Heart Problem
Depression, Anxiety Diabetes Asthma Alcohol or Substance Abuse Other significant issues

* Do you currently have a life insurance policy?

Yes   No  

* What is the coverage on your existing life insurance policy?

* Are you planning to replace this coverage?

Yes   No  

Note: Experts typically recommend that you purchase coverage of 7-10 times the amount of annual income you need to replace.

* Amount of coverage you wish to obtain:

Alternate amount:

* Desired duration of policy (years):

To offer the right rate, insurance companies consider your family's health history an important factor in determining your final price.

If you are adopted, check here and skip the next set of questions.


* Before they turned 70 , did any of your parents or siblings have incidents of or die from heart disease, cancer, stroke, or diabetes?

Yes, the following occurred:


Cancer Heart Diabetes Stroke


Cancer Heart Diabetes Stroke


Cancer Heart Diabetes Stroke

Your lifestyle may include risks that an insurance company must take into account.

* How many tickets have you received for moving violations in the last 3 years?

* How many tickets have you received for moving violations in the last 5 years?

* Have you had any DUI citations?

* Have you smoked cigarettes in the last 5 years?

* Have you used any other forms of tobacco or nicotine in the last 5 years?

* In the past 2 years, did you live or travel outside the U.S. or Canada?

Yes   No  

* In the next 2 years, do you have any plans to live or travel outside the U.S. or Canada?

Yes   No  

* Have you ever flown in an aircraft in any capacity other than a passenger?

Yes   No  

* Have you done any SCUBA diving in the last 3 years ?

Yes   No  

* Do you engage in any hazardous sports or activities?

You're almost done. Thank you for taking the time to answer all of our questions. Now we just need your contact information, so we can be sure you get your quote as quickly as possible.

* Street

* City

* State

* Zip

Office Phone #

* Home Phone #

* E-Mail address: