In order to provide you with an insurance policy price quote, we will need the following information. Once submitted, a Cura Insurance team member will contact you within one business day.

Name

First Name

Last Name

State

In what state do you live?

Phone

(###)

###

####

Date of Birth

YYYY

Face Amount

Enter the amount of life insurance coverage you'd like for the policy(ies).

Product

Term Length

Estimated Health Class

Replacing an Existing Policy?

Will this policy replace an existing life insurance policy you already own?

Yes

Tobacco Use?

Yes

If yes, describe your tobacco use.

Marijuana Use?

Note: We don't share/report this information, however having this information ahead of time may help pair you with a carrier who accepts marijuana use and can provide better rates.

Yes

High-risk Hobbies

(e.g., sky diving, SCUBA diving, etc.)

Yes