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Birth Date


Zip Code*

Email Address*

U.S Citizen*

Do you have a spouse or significant other?*

Have you used any tobacco products in the last 5 years?*






Have you ever been treated for and/or taken medication for any of the following?*

Do you have any parents or siblings who contracted cardiovascular disease (heart attacks or strokes), cancer, diabetes, or kidney disease before age 70?*


What type of Life Insurance your looking for?*

By clicking above, I authorize Genius Solutions to call me and send pre-recorded messages and text messages to me about the products and services at the telephone number I entered above, using an autodialer, even if I am on a national or state “Do Not Call” list. Message and data rates may apply. Maximum 10 texts per month. Consent for calls & texts is optional. You can opt out anytime. You also agree to our Terms of Service.


You decide The type of coverage you need,

how many years your policy will last (the term) and the coverage amount that will be paid out if you die (the death benefit).


You pay for the policy in the form of monthly or annual premiums. You can compare quotes from insurers first to see the different rates they charge for coverage.


If you die while your term life insurance policy is active, the death benefit is paid out to your beneficiaries.


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