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   Place of Birth

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

Full Address (California only)

Day Phone Evening Phone

E-mail

To receive a quick quote please answers a few question:

 Are you United State citizen or do you have Permanent Resident Status (a Green Card)?  Select One Yes No  

Occupation & Employer Annual Income: $

2. Have you been diagnosed as having or been treated by a member of the medical profession for:

a.     Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?  Select One Yes No

b.   Alzheimer’s disease (dementia), Amyotrophic Lateral Sclerosis (ALS), mental retardation or Downs Syndrome or do you require the assistance of another person for dressing, bathing, toileting, or mobility or do you use an oxygen tank??  Select One Yes No

3. Have you, within the past 2 (two) years:

a.   had a heart attack myocardial infarction) or stroke (cerebral vascular accident)?  Select One Yes No

b. had or are now awaiting an organ or bone marrow transplant (except as a donor)? Select One Yes No

c. received or been prescribed radiation or chemo therapy or have you received or been prescribed dialysis? Select One Yes No

d. been confined to a nursing home, hospice, extended care or special treatment facility or are you now hospitalized? Select One Yes No

e used controlled substances such as cocaine, heroin, amphetamines, barbiturates or hallucinogens except as prescribed by a physician or been treated for or been advised by a physician to seek treatment for drug or alcohol use? Select One Yes No

f. been advised by a physician that your life expectancy is less than 24 months? Select One Yes No

g. had more than one DUI (DWI) violation, been convicted of a felony or are you now on probation? Select One Yes No

4. Do you have any other life insurance or annuity now in force? (If Yes, describe in Details section) Select One Yes No

5. Will the issuance of this policy result in the replacement, lapse or termination of any other life insurance or annuity? (If Yes, complete and submit the appropriate State Replacement forms.) Select One Yes No

Details of yes answers