Coventry Submit a Policy

Identify Verification
First Name*
Last Name*
Phone Number*
Email Address*
Policy Death Benefit*
Insured's Date of Birth*
Please enter the date in MM/DD/YYYY format.
MM slash DD slash YYYY
Insured's Age*
Please enter a number from 18 to 130.
Age Instead of DOB
- Use Insured’s Age Instead of DOB
Insured's Health Status*
Insured's Gender*
Are you the insured?*
- Yes, I am the insured
- No, I am not the insured
Terms & Conditions Agreement*
- I agree to the terms & conditions and privacy policy.
Please enter the code sent by mail

Insured Contact Information

In the previous step, you indicated that you are not the insured on the policy. Please provide the insured's contact information.
Insured First Name*
Insured Last Name*
Phone
Email
What is your relationship to the insured?*

Policy Information

We need to evaluate your policy information. Please provide accurate answers or respond "I don't know" if you are unsure.
What is the policy type?*
How long has the policyowner owned the policy?*
Did you receive the policy from a current or former employer?
- Yes
- No

Additional People Insured on the Policy

Some policies insure multiple people, often a spouse or significant other. If the policy insures more than one person, please provide their information.
Is there another insured person on the policy who is still living?*
- Yes
- No
Second insured's First Name
Second insured's Last Name
Second insured's Health Status
Second insured's Date of Birth*
MM slash DD slash YYYY
Second insured Age
Please enter a number from 18 to 130.
Second Insured Age Instead of DOB
- Use Insured’s Age Instead of DOB

Additional Policies

Some people maintain more than one life insurance policy. Evaluating all of your policies at once may improve the insured's ability to qualify.
Do you have any additional life insurance policies?*
- Yes
- No
What is the total death benefit of the additional policy or policies?*

FIND OUT IF YOUR POLICY QUALIFIES