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? Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Face Amount Enter the amount of life insurance coverage you'd like for the policy(ies). $ Product Term (10-40 years) Universal Life (Permanent) Universal Life with Long-Term Care Rider Term Length Estimated Health Class Preferred+ Preferred Standard Table Rated Replacing an Existing Policy? Will this policy replace an existing life insurance policy you already own? Yes No Tobacco Use? Yes No 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 No High-risk Hobbies (e.g., sky diving, SCUBA diving, etc.) Yes No How did you hear about us? Thank you!
