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Submit a Policy

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FIND OUT IF YOUR POLICY QUALIFIES

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
- By checking this box, I consent to receive customer care and promotional/marketing SMS messages from Coventry First, LLC. Reply STOP to opt-out; Reply HELP for help or visit www.coventry.com; Message and data rates apply; Message frequency may vary. Learn more by reading our Privacy Policy and Terms and Conditions.
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

Insured's Health History

Providing an accurate health history is important in determining eligibility.
Has the insured ever been diagnosed with any of the following? Select all that apply.
- ALS (Lou Gehrig's Disease)
- Alzheimer's Disease or Dementia
- Cancer
- Chronic Lung or Respiratory Disease (other than Asthma)
- Heart Disease (Including Pulse or Rhythm Issues)
- Insulin Dependent Diabetes
- Kidney or Renal Disease
- Liver Disease
- Multiple Sclerosis (MS)
- Parkinson's Disease
- Stroke / Cerebrovascular Disease
Cancer
Does the insured have any of the following types of cancer? (Check all that apply.)
- Bladder
- Brain
- Breast
- Colorectal
- Digestive
- Head/Neck
- Kidney
- Leukemia
- Liver
- Lung
- Melanoma
- Multiple Myeloma
- Non-Hodgkin's Lymphoma
- Ovarian
- Pancreatic
- Prostate
- Other
Other Cancer Type
What is the insured's latest stage of cancer?
Is the cancer currently in remission? (Select "No" if any type is not in remission.)
Chronic Lung or Respiratory Disease (other than Asthma)
Does the insured use oxygen?
Does the insured have COPD?
Does the insured have Emphysema?
Heart Disease (Including Pulse or Rhythm Issues)
Does the insured have Congestive Heart Failure?
How many heart attacks has the insured had in the last 3 years?
Insulin Dependent Diabetes
What is the A1C score?
Is the Insulin Dependent Diabetes under control?
Has the insured had any complications?
Kidney or Renal Disease
What is the current stage of the disease?
Does the insured currently require dialysis?
Liver Disease
Does the insured have Cirrhosis?
What is the insured's liver transplant status?
Multiple Sclerosis (MS)
Does the MS affect the insured's bowels, bladder, or ability to walk?
Parkinson's Disease
Does the disease affect the insured's everyday life?
Stroke / Cerebrovascular Disease
How many strokes or TIAs has the insured had?
Does the disease affect the insured's everyday life?
This field is hidden when viewing the form
Does the insured use any assistive devices or ongoing medical support such as homecare hospice or continuous therapy?
- Yes
- No
Please explain assistive devices / medical support
Please provide any additional health information for the insured that you would like us to consider.

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?*

How did you hear about Coventry Direct?*
TV Options
Please select the channel or program
Radio Options
Please select the channel or program
Internet / Social Media Options
Please select an Internet / Social Media option
Comments
This field is for validation purposes and should be left unchanged.

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