Final Expense (California only)

 Are you prepared for Final Expenses?

According to the US Senate Committee on aging, the average cost of a funeral is approximately $8,495

This total may include such expenses as:  

• Vault, Cemetery, Casket, Graveside, Professional Services.
• Additional Costs may include: Unpaid Medical Bills, Unpaid Debt, Taxes, Nursing Home, and Medicare Deductibles.
• Social Security only pays $225 for burial expenses, if you qualify.
• Burial Insurance or Final Expense Insurance may help provide help with the necessary funds to pay these final burial expenses. Based on your answers to a few medical questions, you may qualify for up to $50,000 Up to age 80 of permanent whole life insurance.
• Permanent policy with a level premium regardless of your increasing age.
• Peace of mind that your loved ones are cared for.

To receive a quick quote please answers a few question:

Date of Birth Month Jan Fab Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Gender Select Male Female

Height - 4 5 6 7 ft - 0 1 2 3 4 5 6 7 8 9 10 11 in  Weight lbs

Tobacco/Nicotine Use Select... Never used Current user Last use over 5 years ago Last use over 3 years ago Last use over 2 years ago Last use over 1 years ago Quit within the last year

First Name

Last Name

Day Phone Evening Phone

E-mail

To receive a quick quote please answers a few question:

Section I

A.    Do you currently receive kidney dialysis or require oxygen use or have you been diagnosed as having a terminal illness? (Terminal illness is defined as any illness diagnosed that would reasonably be expected to cause death within twenty-four (24) months.)  Select One Yes No  

B.     Do you require assistance to eat, bathe, dress or take your own medication or are you currently confined to a hospital, nursing home, mental facility or Hospice or have you been hospitalized two or more times in the past twelve months?  Select One Yes No

C.    Has the proposed insured ever been diagnosed as having or been treated for AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS Related Complex) by a member of the medical profession, or tested positive for HIV antibodies as part of a test conducted for the purpose of obtaining insurance?  Select One Yes No

Section II

A.    In the pasts years, have you been diagnosed or treated for, or are you currently under treatment for Alzheimer’s Disease, any form of Cancer (other than Basal Cell skin cancer), Heart or Circulatory Disorder (except controlled hypertension), Sickle Cell Anemia, Stroke, Kidney Disease (including dialysis), Liver Disease, any Lung Disease (except mild asthma not requiring daily medication), ALS (Lou Gehrig’s Disease) or other neurological disorders (except for controlled seizure disorder with no seizures in the past 2 years), or surgery for any Heart or Circulatory Disorder (except varicose veins) or transplant of any organ?  Select One Yes No

B.   Are you currently disabled or been disabled in the last six months, or at any time during the last six months been unable to mentally or physically complete 30 hours per week of active employment or have you been declined or postponed tot Life or Health Insurance in the past two years?  Select One Yes No

C.   In the past 10 years have you been convicted of a felony; or in the pasts years have you been treated for, been advised to have treatment hr or excessively used alcohol or any drug abuse?  Select One Yes No

Section III

A.   In the past 5 years, have you been diagnosed or treated for, or are you currently under treatment for Schizophrenia, Bipolar Disorder, Diabetes requiring insulin treatment, SLE (Systemic Lupus Erythematosus)?  Select One Yes No

B.   In the past 5 years, have you been convicted of operating a vehicle while intoxicated, or had your drivers license suspended or revoked?  Select One Yes No

C.   Do you now participate in, or do you have plans to participate in any hazardous is sports or aviation? Select One Yes No