ALLiS Login | phone icon (877) 254-4429

Quote Request: Hybrid Life

For the most accurate quote possible, please complete all fields. We keep all data strictly confidential - please see our Privacy Policy. Please do not hit "Enter" or click "Send Quote Request" until the form has been completed. For serious health problems or unusual circumstances, please call (toll free) 877-254-4429 for a no-cost, confidential consultation. *Red = Required Field.

Advisor Information

Proposed Insured

Contact Information

Current Address

Household Information

Occupation

Hybrid Life Options

Not available with all payment options.

Not available in all states or with all payment options.

** Please have your spouse/partner complete his/her own quote request.

Lifestyle Details

Tobacco/Nicotine Type 1

Example: 1 pack daily

HOW MANY HOURS HAVE YOU FLOWN IN THE LAST...

ADDITIONAL HOURS QUESTIONS

ADDITIONAL QUESTIONS

Please specify the number of dives and average time underwater per dive for the depth ranges below:

Please specify the number of dives and average time underwater per dive for the depth ranges below:

Please include date and location

Health Details

Have you EVER been diagnosed with, treated for, hospitalized for or been advised to seek treatment for:

Example: Diagnosed with elevated blood pressure 2 years ago – take 20 mg Lisinopril daily – last reading 128/82

Example: High Cholesterol – July 2014 – take Crestor 20mg / day – had physical in May – readings were great

Cancer Type 1

Example: Nightly use of CPAP

Family History

Mother

Father

Siblings

Example: Brother, living, age 54, dx with heart disease at age 50

Delivery Options

Additional details you'd like to include to help us with the quote.