Life Insurance Questions for Quote Once we have the information completed below, we will contact you with quote options for you to review. Name(Required) First Last Height(Required)Weight(Required)Do you use nicotine(Required)NoYesDo you use medical or recreational marijuana(Required)NoYesWhat type consumed(Required)SmokedEdiblesBothFamily History: Has there been a death prior to age 65 of your mother, father or sibling(Required)NoYesPlease list the person and cause of death(Required)Are you currently taking any prescribed medications(Required)NoYesWhat medications are you taking and what are they for(Required)Have you had or currently have cancer, diabetes or heart issues(Required)NoYesWhat is the condition and what is the current status of the condition(Required)