BIA Marketing Services

Preferred/Standard Rates:

Preferred rates are not available to every customer. Generally, you must be in good health in order to receive the preferred rate. These rates are determined and subject to change based upon your application and medical history, our underwriting requirements, and any additional benefits you may select.

For applicants under age 40, to qualify for preferred rates, your cholesterol readings, if known, must be under 220 and your blood pressure readings, if known, must be under 140/90 bp.

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* Required fields

General Information

* Zip Code:

* Requested Effective Date: mm/dd/yyyy

Primary Information

* Gender:

* Date of Birth: mm/dd/yyyy

* Risk Class: ^?

Preferred

Standard

* Tobacco User:

Yes

No

Spouse Information

* Spouse Gender:

* Date of Birth: mm/dd/yyyy

* Risk Class: ^?

Preferred

Standard

* Tobacco User:

Yes

No

Dependent Information

* Number of Dependents: