Product Name

Product Description

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Zip Code (primary home)

Gender

Date of Birth

Are you a AAA member?

You don’t need to be a AAA member to apply for life insurance. However, members of AAA do receive some perks – learn more about joining AAA.

Yes No

Choose a Term Life product:

ExpressTerm

$25,000 to $500,000 in coverage
10, 15, 20, or 30-year term
Buy online

Traditional Term

$100,000 to $5,000,000 in coverage
10, 15, 20, 25, or 30-year term
Buy with an agent

Are you replacing an existing policy?

Yes No

Height

Weight

When was the last time you used any type of nicotine product?

Nicotine products include any of the following: cigarettes, cigars, electronic cigarettes, chewing tobacco, nicotine gum, nicotine patches, pipes, or hookah.

Rate Your Health

Overall Health Guidelines for ExpressTerm

While it is not possible to know your rate class with 100% certainty until your case is evaluated by the ExpressApprove automated underwriting engine, the following is provided to give you some general guidance as to what you might expect.

If you qualify for a different rate than the one you select, don't worry - we will let you know and explain your options.

Fair

If you don’t qualify for the other rates due to certain other medical conditions you may qualify for this rate.

Good

You may qualify for the “Good” rate if you are in generally good health and haven’t used nicotine at all for at least the past 12 months, and

No history of uncontrolled high blood pressure or it is controlled with medication

No personal history of heart disease or cancer (other than skin cancer)

Never had complications due to diabetes

No alcohol or drug abuse

No felony convictions

Excellent

You may qualify for the best or “Excellent” rate if you are in generally good health and haven’t used nicotine at all for at least the past 36 months, and

No history of high blood pressure

No personal history of heart disease or cancer (other than skin cancer)

Never diagnosed or treated for diabetes or elevated blood sugar

No alcohol or drug abuse

No felony convictions

Overall Health Guidelines for Traditional Term

This chart outlines some of the key criteria used to evaluate your health condition status. While we cannot fully determine your rate class until your policy has been underwritten, the information below will provide you with a general idea.

Fair

Nicotine/Tobacco

No nicotine or tobacco use in the past:

13-35 months

Blood Pressure

Blood pressure not exceeding:

150/95 for ages 18-69

155/90 for ages 70+

History of Hypertension:

Well controlled with 3 or fewer medications

Cholesterol

Cholesterol between:

140 to 325

Cholesterol/HDL ratio not exceeding:

7.0 for ages 18-69

8.0 for ages 70+

If applicable, elevated cholesterol is:

Well Controlled with treatment

Other Health Conditions

History of heart disease:

No history

History of diabetes:

No history

History of Cancer:

No history

History of Drug or Alcohol Abuse:

None for 6+ years

Family history of heart disease and/or cancer:

2 parents/siblings died from cancer or heart disease prior to age 60

Legal History

Moving violations while driving:

4 or less in last 3 years

Driving under the influence (DUI) convictions:

None in the last 3 years

Good

Nicotine/Tobacco

No nicotine or tobacco use in the past:

36-59 months

Blood Pressure

Blood Pressure not exceeding:

145/90 for ages 18-69

145/90 for ages 70+

History of Hypertension:

Well controlled with 2 or fewer medications

Cholesterol

Cholesterol between:

140 to 325

Cholesterol/HDL ratio not exceeding:

5.5

If applicable, elevated cholesterol is:

Well Controlled with treatment

Other Health Conditions

History of heart disease:

No history

History of diabetes:

No history

History of Cancer:

No history

History of Drug or Alcohol Abuse:

None for 10+ years

Family history of heart disease and/or cancer:

No family history of death from heart disease or cancer prior to age 60

Legal History

Moving violations while driving:

3 or less in last 3 years

Driving under the influence (DUI) convictions:

None in the last 5 years

Excellent

Nicotine/Tobacco

No nicotine or tobacco use in the past:

60+ months

Blood Pressure

Blood Pressure not exceeding:

135/85 for ages 18-69

140/85 for ages 70+

History of Hypertension:

Well controlled with 1 medication only

Cholesterol

Cholesterol between:

140 to 325

Cholesterol/HDL ratio not exceeding:

4.5

If applicable, elevated cholesterol is:

Well controlled with treatment

Other Health Conditions

History of heart disease:

No history

History of diabetes:

No history

History of Cancer:

No history

History of Drug or Alcohol Abuse:

Never

Family history of heart disease and/or cancer:

No family history or diagnosis of heart disease or cancer prior to age 60

Legal History

Moving violations while driving:

2 or less in last 3 years

Driving under the influence (DUI) convictions:

None in the last 5 years

Fair

Nicotine/Tobacco

No nicotine or tobacco use in the past:

Used last 12 Months

Blood Pressure

Blood pressure not exceeding:

150/95 for ages 18-69

155/90 for ages 70+

History of Hypertension:

Well controlled with 3 or fewer medications

Cholesterol

Cholesterol between:

140 to 325

Cholesterol/HDL ratio not exceeding:

7.0 for ages 18-69

8.0 for ages 70+

If applicable, elevated cholesterol is:

Well Controlled with treatment

Other Health Conditions

History of heart disease:

No history

History of diabetes:

No history

History of Cancer:

No history

History of Drug or Alcohol Abuse:

None for 6+ years

Family history of heart disease and/or cancer:

2 parents/siblings died from cancer or heart disease prior to age 60

Legal History

Moving violations while driving:

4 or less in last 3 years

Driving under the influence (DUI) convictions:

None in the last 3 years

Good

Nicotine/Tobacco

No nicotine or tobacco use in the past:

Used last 12 Months

Blood Pressure

Blood Pressure not exceeding:

145/90 for ages 18-69

145/90 for ages 70+

History of Hypertension:

Well controlled with 2 or fewer medications

Cholesterol

Cholesterol between:

140 to 325

Cholesterol/HDL ratio not exceeding:

5.5

If applicable, elevated cholesterol is:

Well Controlled with treatment

Other Health Conditions

History of heart disease:

No history

History of diabetes:

No history

History of Cancer:

No history

History of Drug or Alcohol Abuse:

None for 10+ years

Family history of heart disease and/or cancer:

No family history or diagnosis of heart disease or cancer prior to age 60

Legal History

Moving violations while driving:

3 or less in last 3 years

Driving under the influence (DUI) convictions:

None in the last 5 years

Excellent

Nicotine/Tobacco

No nicotine or tobacco use in the past:

Used last 12 Months

Blood Pressure

Blood Pressure not exceeding:

135/85 for ages 18-69

140/85 for ages 70+

History of Hypertension:

Well controlled with 1 medication only

Cholesterol

Cholesterol between:

140 to 325

Cholesterol/HDL ratio not exceeding:

4.5

If applicable, elevated cholesterol is:

Well controlled with treatment

Other Health Conditions

History of heart disease:

No history

History of diabetes:

No history

History of Cancer:

No history

History of Drug or Alcohol Abuse:

Never

Family history of heart disease and/or cancer:

No family history or diagnosis of heart disease or cancer prior to age 60

Legal History

Moving violations while driving:

2 or less in last 3 years

Driving under the influence (DUI) convictions:

None in the last 5 years

Coverage Amount

Term Length

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