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When were you born?

Date(Required)

MM slash DD slash YYYY

Zip Code(Required)

Why We Request Your Age

Your age helps us match you with the most suitable life insurance options. No matter your stage in life, coverage can provide reassurance and financial protection for those who matter most.

Please select your gender

Gender(Required)

♂ Male

♀ Female

Why We Request Your Gender

Your gender can impact life expectancy, helping us match you with life insurance options that better fit your needs.

How would you describe your overall health?

How would you describe your overall health?(Required)

ExcellentYou're in excellent overall health, maintain a healthy weight, and do not use tobacco. You have no known medical conditions, with cholesterol and blood pressure within normal ranges, and you typically only visit your doctor for routine checkups. There is no history of heart disease or cancer in your immediate family before age 60.

Above AverageYou're in solid overall health and within a healthy weight range, with perhaps a minor concern like slightly elevated blood pressure or borderline cholesterol. Medical visits are infrequent and typically limited to routine checkups.

AverageYou may have a few health conditions, but they are well-managed. You could be slightly above your ideal weight and have elevated cholesterol or blood pressure that is kept under control with medication. You maintain regular checkups to monitor your health.

Below AverageYou are dealing with major health conditions that require ongoing treatment and regular medical care, such as obesity, diabetes, or cancer.

Why We Ask About Your Health

No matter your age or current health status, we use this information to connect you with coverage options that fit your needs.

Please provide your height and weight

Current Height(Required)

Current Weight(Required)

Why We Ask About Your Height and Weight

Height and weight are part of how we understand your health profile and identify coverage that fits. Wherever you are today, we focus on finding options that move you forward.

Where are you located?

Zip Code(Required)

State(Required)

Why We Ask About Your Location

Your location helps us identify which life insurance options are available in your state.

Do you currently have life insurance overage?

Do you currently have life insurance overage?(Required)

Yes

Current Coverage Amount(Required)

Why We Ask About Your Current Coverage

Knowing what coverage you already have helps us identify any gaps and recommend options that build on or improve your protection.

What type of insurance are you interested in?

What type of insurance are you interested in?(Required)

TermYou select the policy duration, with terms commonly ranging from 10 to 30 years. It's often one of the most cost-effective life insurance options.

I'm not sureWith so many life insurance options available, the process can feel overwhelming. We take the time to understand your needs and help you find coverage that fits both your goals and your budget.

Why We Ask About Your Preferred Type of Life Insurance

Your selection helps us connect you with the most suitable options from the insurance providers we work with.

What is your individual annual income from salary and wages?

What is your individual annual income from salary and wages?(Required)

Less than $50,000

$50,000 - $99,999

$100,000 - $149,999

$150,000 - $199,999

$200,000 - $249,999

$250,000 - $299,999

$300,000 - $399,999

$400,000 - $499,999

Over $500,000

N/A: On Disability Income

Why We Ask About Your Income

This refers to your total yearly earnings before taxes from salary or wages. Be sure to include bonuses, commissions, freelance income, or other variable pay to reflect your full annual income.

How much coverage do you need?

Coverage Amount(Required)

Length of Term(Required)

Why We Ask About Coverage Amount

Understanding how much coverage you need helps us recommend policies that adequately protect your family and fit your budget.

Have you ever used Tobacco or Nicotine products?

Have you ever used Tobacco or Nicotine products?(Required)

Yes

Understanding Your Tobacco Use

Being upfront about your tobacco and nicotine use allows us to provide the most accurate quotes possible. We partner with a wide range of carriers who offer competitive rates for all applicants, including those who smoke.

Check all conditions for which you've been treated:

Check all conditions for which you've been treated:(Required)

Alcohol or Substance Abuse

Asthma

Blood Clot

Blood Pressure

Cancer

Cholesterol

Depression or Anxiety

Diabetes

Heart Issue

HIV/AIDS

Sleep Apnea

Stroke

None of these

Understanding Your Health Background

Your personal health history allows us to connect you with the most relevant coverage options. We partner with carriers who offer competitive rates for a wide range of health profiles, including those with pre-existing conditions.

Have you been cited for impaired driving or had more than 3 driving violations in the past 5 years?

Do you currently engage in any of these sports or activities?(Required)

Yes

Understanding Your Driving History

Your driving history is one factor insurers use to evaluate overall risk. Regardless of your record, we work with a variety of carriers to help identify coverage that fits your individual situation.

Do you currently engage in any of these sports or activities?

Do you currently engage in any of these sports or activities?(Required)

Piloting aircraft, Bungee jumping, Mountain & rock climbing, Hang gliding, Scuba diving, Skydiving

Yes

Understanding Your Activity Profile

Participation in certain activities is a factor carriers consider when determining coverage. Whatever your lifestyle, our goal is to find a policy that gives you the protection you deserve.

Did your parents or siblings have heart disease, cancer, stroke, or diabetes before age 65?

Did your parents or siblings have heart disease, cancer, stroke, or diabetes before age 65?(Required)

Yes

Understanding Your Family Health Background

A family history of certain conditions gives insurers context about potential inherited health risks. This information helps us identify policies that account for your full picture and are the right fit for you.

Have you been declined for life insurance in the past year?

Have you been declined for life insurance in the past year?(Required)

Yes

Understanding Prior Coverage Decisions

A previous denial can affect the quoting process, so knowing this upfront helps us set realistic expectations and direct you toward carriers best suited to your circumstances.

Do you consume more than 4 alcoholic beverages per day?

Do you consume more than 4 alcoholic beverages per day?(Required)

Yes

Email(Required)

Understanding Your Lifestyle Choices

Information about alcohol consumption helps us identify the coverage options that best align with your overall lifestyle and individual profile.

Do you use marijuana daily?

Do you use marijuana daily?(Required)

Yes

Understanding Your Lifestyle Choices

Information about marijuana use helps us identify the coverage options that best align with your overall lifestyle and individual profile.

Are you currently using narcotics or opioids for pain?

Are you currently using narcotics or opioids for pain?(Required)

Yes

Understanding Your Pain Management

Knowing whether you currently use prescription pain medication allows us to match you with a carrier whose products are designed to accommodate your specific health needs.

Have you been convicted of a felony in the past 10 years?

Have you been convicted of a felony in the past 10 years?(Required)

Yes

Understanding Your Legal Background

Your criminal history is one of many factors insurers consider when evaluating coverage eligibility. Whatever your background, we'll work to connect you with the right options for your situation.

Who are we preparing this quote for?

Name(Required)

First Last

Why We Need Your Address

Your home address helps finalize your application details and may factor into your premium calculation. We use this information solely to help secure the best possible coverage for you.

Where do you live?

Address(Required)

City(Required)

State(Required)

ZIP(Required)

Why We Need Your Address

Your home address helps finalize your application details and may factor into your premium calculation. We use this information solely to help secure the best possible coverage for you.

What's the best number to reach you at if we have any questions about your request?

Phone(Required)

By submitting your quote request, you provide your electronic signature and express written consent for B-QUOTED and its insurance partners to contact you by phone, text, or email using the number provided, including automated systems. Your consent is not required to receive a quote. Message and data rates may apply. Text STOP to cancel. You agree to our Privacy Privacy Policy and Terms and Conditions.

Why We Need Your Phone Number

Having a valid phone number on file means we can reach you quickly with quote details, policy options, or answers to any questions you may have along the way.

How did you hear about us? (Optional)

Options

How You Found Us

Learning how you came across B-QUOTED helps us refine how we share our services and reach more people who could benefit from better coverage options.