(866) INSUBUY
(866) 467-8289
8 AM - 9 PM CT Seven Days a Week Source ID: Insubuy
(866) INSUBUY467-82898 AM - 9 PM CTSeven Days a Week

Individual Life Insurance Quote Request Form

There was a problem, please make the requested changes and submit again:

  • {{ error.message }}

Thank you for contacting us. We will get back to you within 2 business days.

There was a problem, please make the requested changes and submit again:

  • {{ error.message }}
  • {{ error.message }}

Please provide us as much information as possible for the most accurate quotes, and we would be glad to provide you with free and no obligation individual life insurance quotes.

The information you provide will be kept strictly confidential and will be used for quoting purposes only.

By submitting this quote request, you agree and understand that the quotes you receive will be the best estimation based on the information you provide and final quotes based upon underwriting may vary, which can only be determined after you have submitted the application. Also, you agree that you are not guaranteed issue of the life insurance policy until it goes through underwriting. Once you receive the underwritten policy with final rates, you will have 10 days to decide whether you would like to accept the insurance policy.

Your request has been sent!

Back to Quote Form.

Contact Details *Required

Title is required.

First Name is required.

Last Name is required.

State is required.

Zip Code is required.

A valid number is required it cannot contain alphabets or fraction.

A valid Day or Evening Phone Number is required.

A valid Email Address is required.

Coverage Details

Coverage Amount is required.

Coverage Type is required.

Payment Frequency is required.

Personal Details

Birth Date is required.

Birthdate cannot be today.

Birthdate cannot be in future.

Please enter the Birth Date in the specified format.

ft.
in.

Height is required (Eg: if 6.0 enter 6 ft 0 in).

A valid number is required it cannot contain alphabets or fraction.

lb.

Weight is required.

A valid number is required it cannot contain alphabets or fraction.

Gender is required.

Occupation is required.

Legal Status is required.

Legal Status (Other) is required.

Legal Status (Other) is required.

Lifestyle Details

Aviation *

Aviation is required.

Any private piloting, military aviation, or ratable business flying?

Avocation *

Avocation is required.

Any ratable activities such as drag racing at speeds over 120 mph, scuba diving 101-130 feet with Basic Open Water Certification?
Any hazardous activities such as automobile/motorcycle racing, sky diving, scuba diving, bungee jumping?

Driving Record *

DWI/DUI is required.

License Suspention is required.

No. of Citations is required.

A valid number is required it cannot contain alphabets or fraction.

Number of years is required.

A valid number is required it cannot contain alphabets or fraction.

Number of years is required.

A valid number is required it cannot contain alphabets or fraction.

Any driving while intoxicated (DWI/DUI) or reckless driving?
If yes, within last how many years?
Any license suspension?
If yes, within last how many years?
No. of citations (tickets) for either moving violations or motor vehicle accidents within the last 3 years:

Tobacco Usage *

Tobacco Usage is required.

Number of months is required.

A valid number is required it cannot contain alphabets or fraction.

Number of tobaccos used is required.

A valid number is required it cannot contain alphabets or fraction.

Times Per Tobacco is required.

Usage Types is required.

months
times per
If you ever used tobacco, please provide the usage types:

Alcohol/Drug *

Alcohol/Drug is required.

Number of years is required.

A valid number is required it cannot contain alphabets or fraction.

Any history of alcohol/drug abuse or treatment:
If yes, within last how many years:

Travel *

Travel Outside the U.S is required.

Plans to travel outside U.S is required.

Countries that you have planed to travel is required.

Plans to settle outside U.S is required.

Country that you have planed to settle down is required.

Social Security Number is required.

Since when US resident is required.

Travel outside the U.S. for business or vacation:per year.
In above question, please specify total duration of travel per year.
If you do travel, which countries?
Do you plan to travel outside the U.S. within the next 1 year?
If yes, which countries:
Do you have any known plans to settle down outside the U.S.?
If yes, which country and appoximately when?
If non U.S. citizen,
Have Social Security Number?
Since when have you been a full-time resident of the U.S.?

Health Details

Family History *

Family History is required.

Family History age is required.

A valid number is required it cannot contain alphabets or fraction.

Any death of a parent or sibling due to Coronary Artery Disease (CAD), Cerebrovascular Disease (CVD), Diabetes Mellitus, or Cancer?
If yes, at what age:

Blood Pressure

With or without Medication is required.

/

Cholesterol

With or without Medication is required.

Cholesterol/High Density Lipid (HDL) ratio:

Health Conditions

Please answer truthfully:

Please provide details of any and all health conditions you have (or had in the past year):

If on medication, please give drug(s), dosage, and frequency:

If hospitalized, please give dates and details:

Any other comments or special requirements:

Verification Code is required.

CAPTCHAreload

Error(s) occurred. Please scroll above to view.

Did you know?

Prices are regulated by law.

You cannot find a lower price anywhere for the same product.

Learn More

Why purchase insurance from Insubuy®?

Same Price. Better Service.®

There are many advantages in purchasing from Insubuy® and no disadvantages.

Learn More

Visiting USA?

Healthcare costs are very high in the U.S.

Buy U.S. based visitors insurance and enjoy your trip.

Learn More

Traveling abroad?

Did you know that your insurance may not cover you abroad or that it may only provide limited coverage?

Purchase travel medical insurance that includes emergency medical evacuation.

Learn More

New immigrant to USA?

You are not eligible to enroll in Medicare for the first 5 years.

Purchase new immigrant medical insurance to bridge the gap.

Learn More

Going on a vacation?

You could lose your non-refundable trip costs if you had to cancel your trip.

Buy a trip cancellation insurance package plan and be worry-free.

Learn More

Are you an exchange visitor to USA?

The U.S. Department of State requires all J visa holders to purchase compliant insurance.

Buy J visa medical insurance to meet your requirements.

Learn More

Traveling to Europe?

Schengen countries require most non-US citizens to purchase Schengen visa insurance.

Make an instant purchase online and get instant visa letter.

Learn More

Traveling frequently throughout the year?

You don't need to purchase travel insurance for every trip.

Purchase annual multi trip travel insurance for your travels.

Learn More

International student in the U.S.?

Most schools require international students to purchase health insurance.

Purchase international student health insurance that meets most school requirements.

Learn More