Welcome to FastLife

Name

Email

Phone

Date Of Birth

Gender
MaleFemale

Tobacco user?
NoYes

Do you have diabetes?
NoYes

If yes, how long ago were you diagnosed?

Do you currently take:
InsulinOral MedicationBothNo Diabetes Medication

If you have diabetes, what is your A1C level?

What State Do You Live In?

Height

Weight

Amount of Coverage Desired
---$25,000$50,000$100,000$150,000 - $199,999$200,000 - $299,999$300,000 - $399,999$400,000 - $499,999$500,000 - $599,999$600,000 - $699,999$700,000 - $799,999$800,000 - $899,999$900,000 - $999,999$1,000,000 or greater

Length of Coverage Desired
---10 Years15 Years20 Years30 YearsPermanent

Are you taking any medications?
No MedicationsHigh Blood Pressure MedicationCholesterol MedicationThyroid MedicationOther Medications (please list below)

Other

Please describe any hospitalization or medical treatment in the last five years (when & for what)

Where did you hear about us?
RadioNewspaperDirect MailTelevisionInternetReferral