Birth Date:

January February March April May June July August September October November December   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   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

Sex:

Male  Female

Smoker/
use tobacco?:

Yes  No 

Describe your
Health:

Regular  Regular Plus
PreferredPreferred Plus  

Mortgage Term:

10 Year Mortgage Term **15 Year Mortgage Term ** 20 Year Mortgage Term **25 Year Mortgage Term ** 30 Year Mortgage Term ** ---------------------------------------- 10 Year Mortg Term Guaranteed 15 Year Mortg Term Guaranteed20 Year Mortg Term Guaranteed25 Year Mortg Term Guaranteed 30 Year Mortg Term Guaranteed ------------------------------------ 15 Year Mortg - Return of Premium 20 Year Mortg - Return of Premium 30 Year Mortg - Return of Premium

Amount owed on Mortgage:

$50,000  $75,000  $100,000  $150,000  $200,000  $250,000  $300,000  $350,000  $400,000  $450,000  $500,000  $600,000  $700,000  $750,000  $800,000  $900,000  $1,000,000  $1,250,000  $1,500,000  $1,750,000  $2,000,000  $2,500,000  $3,000,000  $5,000,000

Premiums Paid:

Annual  Monthly