iTravelHealth.com

PRIMARY TO BE INSURED

First Name:

Last Name:

E-Mail:

Are you a resident of Missouri?
Yes
No

Zipcode:

Gender
Male
Female

Date of Birth:

Have you used tobacco products at any time during the past 3 years?
Yes
No

Have you smoked more than 9 cigarettes per day?
Yes
No

Have you smoked more than 1 cigar or pipe per day?
Yes
No

Are you within the weight range listed in the build chart below?
Yes
No

Preferred Rating Build Chart
Male		Female
Height (FT,IN)	Weight (lbs)	Height (FT,IN)	Weight (lbs)
5'0"	98-152	4'10"	90-138
5'1"	101-155	4'11"	92-140
5'2"	103-159	5'0"	94-143
5'3"	105-162	5'1"	96-146
5'4"	107-166	5'2"	98-150
5'5"	110-171	5'3"	101-153
5'6"	112-175	5'4"	104-158
5'7"	115-181	5'5"	107-163
5'8"	118-186	5'6"	109-168
5'9"	121-191	5'7"	112-173
5'10"	124-197	5'8"	115-178
5'11"	126-203	5'9"	117-185
6'0"	129-208	5'10"	119-192
6'1"	132-215	5'11"	122-197
6'2"	135-220	6'0"	123-202
6'3"	139-226	6'1"	126-207
6'4"	143-232	6'2"	130-213
6'5"	146-240	6'3"	134-219

Do you have normal blood pressure and cholesterol levels? (If over age 40, see chart below...)
Yes
No

Age	Exam Requirements	Readings
40-49	within past 3 years	140/90 blood pressure and cholesterol under 220
50 and older	within past 2 years	140/90 blood pressure and cholesterol under 220

Do you have medical conditions that require a rating or a rider or take medications that require an underwriting action?
Yes
No

Number of Depenent Children to be Covered: 1 2 3 4 5 6 7 8 9 10

SPOUSE

Do you wish to include your spouse on this plan?
Yes
No

Complete This Portion Only If Spouse Is To Be Covered By This Plan SPOUSE TO BE INSURED First Name: Last Name: E-Mail: Is Spouse a resident of Missouri? Yes No Zipcode: Gender Male Female Date of Birth: Have you used tobacco products at any time during the past 3 years? Yes No Have you smoked more than 9 cigarettes per day? Yes No Have you smoked more than 1 cigar or pipe per day? Yes No Are you within the weight range listed in the build chart below? Yes No Preferred Rating Build Chart Male Female Height (FT,IN) Weight (lbs) Height (FT,IN) Weight (lbs) 5'0" 98-152 4'10" 90-138 5'1" 101-155 4'11" 92-140 5'2" 103-159 5'0" 94-143 5'3" 105-162 5'1" 96-146 5'4" 107-166 5'2" 98-150 5'5" 110-171 5'3" 101-153 5'6" 112-175 5'4" 104-158 5'7" 115-181 5'5" 107-163 5'8" 118-186 5'6" 109-168 5'9" 121-191 5'7" 112-173 5'10" 124-197 5'8" 115-178 5'11" 126-203 5'9" 117-185 6'0" 129-208 5'10" 119-192 6'1" 132-215 5'11" 122-197 6'2" 135-220 6'0" 123-202 6'3" 139-226 6'1" 126-207 6'4" 143-232 6'2" 130-213 6'5" 146-240 6'3" 134-219 Do you have normal blood pressure and cholesterol levels? (If over age 40, see chart below...) Yes No Age Exam Requirements Readings 40-49 within past 3 years 140/90 blood pressure and cholesterol under 220 50 and older within past 2 years 140/90 blood pressure and cholesterol under 220 Do you have medical conditions that require a rating or a rider or take medications that require an underwriting action? Yes No

After completing the quote application, click on the "Get Quote" button below. Your application will be sent to a qualified broker and a preliminary quote will returned to you within two business days.