Find out if your policy qualifies Find out if your policy qualifies to be sold for cash in just a few minutes. Contact Info Policy Info Insured Info Health Info First Name * Last Name * Phone Number * Email Address * I agree to the terms & conditions and privacy policy. Next For full functionality of this site it is necessary to enable JavaScript. Here are the instructions how to enable JavaScript in your web browser. Policy Death Benefit * Policy Type * Select One... Term Life Universal Life Whole Life Other I don't know Back Next Insured's Gender * Select One... Male Female Insured's Date of Birth * Insured's Health Status * Select One... Excellent Good Fair Poor Terminal Back Next Has the insured ever been diagnosed with any of the following conditions? ALS (Lou Gehrig’s Disease) Alzheimer’s Disease or Dementia Cancer Chronic Lung or Respiratory Disease (excluding Asthma) Heart Disease, including pulse or rhythm issues Insulin Dependent Diabetes Kidney or Renal Disease Liver Disease Multiple Sclerosis (MS) Parkinson’s Disease Stroke / Cerebrovascular Disease Do you use any assistive devices or require ongoing medical support? Yes No Is there anything else we should know about your health history? Yes No Cancer Do you currently, or have you had, any of the following types of cancer? (Select all that apply) Bladder Brain Breast Colorectal Digestive Head / Neck Kidney Leukemia Liver Lung Melanoma Multiple Myeloma Non-Hodgkin’s Lymphoma Ovarian Pancreatic Prostate Other What stage is the most advanced cancer in? I Don’t Know Stage 1 Stage 2 Stage 3 Stage 4 Is your cancer currently in remission? Chronic Lung or Respiratory Disease Does the insured use oxygen? Select One... Yes No I don't know Does the insured have COPD? Select One... Yes No I don't know Does the insured have Emphysema? Select One... Yes No I don't know Cancer Does the insured have Congestive Heart Failure? Select One... Yes No I don't know How many heart attacks has the insured had in the last 3 years? Select One... 0 1 2 3+ Diabetes What is the A1C score? Select One... Under 6 6 to 7.4 7.5+ I don't know Is the Insulin Dependent Diabetes under control? Select One... Yes No I don't know Has the insured had any complications? Kidney or Renal Disease What is the current stage of the disease? Select One... Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 I don't know Does the insured currently require dialysis? Select One... Yes No I don't know Liver Does the insured have Cirrhosis? Select One... Yes No I don't know What is the insured's liver transplant status? Select One... Completed On list (pending) Not applicable I don't know Multiple Sclerosis Does the MS affect the insured's bowels, bladder, or ability to walk? Select One... Yes No I don't know Parkinson’s Disease Does the disease affect the insured's everyday life? Select One... Yes No I don't know Stroke / Cerebrovascular Disease How many strokes or TIAs has the insured had? Select One... 0 1 2 3+ I don't know Does the disease affect the insured's everyday life? Select One... Yes No I don't know Back Submit
