Life Insurance Pre-Screen (2026)

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Name
First Name
Last Name
2
Email
example@example.com
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Phone Number
Please enter a valid phone number.
4
What state were you born in?
5
How many years have you lived at your current residency?
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Do you use tobacco products or have you used tobacco products within the last 12 months?
YESNO
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Please provide frequency, type and how long you've been using tobacco.
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Do you use marijuana or have you used marijuana in the past 12 months?
YESNO
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Please provide more detail.
Please Select
Please Select
Medicinally
Recreationally
Do you use recreationally or medicinally?
What is the reason for use? (ex. Anxiety, Pain Management, PTSD, General Recreation, Sleep Disorders, etc.)
Date Last Used
Please Select
Please Select
Day
Week
Month
Years
Frequency: 3x per (select from dropdown)
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PrescriptionsPlease list all current and previous prescriptions you've taken in the last 5 years.
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Alcohol Usage
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Have you been diagnosed or treated for any of the following conditions within the past 10 years: AIDS/HIV Positive, Parkinson’s Disease, Peripheral Vascular Disease, Alzheimer’s Disease, Rheumatoid Arthritis, Cancer, Sleep Apnea COPD (emphysema), Epilepsy, High Blood Pressure, Strokes, Cirrhosis, High Cholesterol (controlled), Coronary Artery Disease, Asthma, Heart Attack, Multiple Sclerosis, Hepatitis, Aneurysm, Kidney Disease/Failure, Organ Transplants, Diabetes, Lupus, Cardiovascular Disease, Mental Disorders, Anxiety/Depression?If YES, please describe in more detail on the Comments page.
YESNO
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Use this page to describe in more detail any question(s) you answered YES to on the previous pages or any medical conditions you may have that weren't listed on the previous slide.We may reach out for further clarification before an application is submitted if a certain disease or diagnosis is noted.
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Do you currently have life insurance? If so, who with and how much? Term / Whole Life / Universal Life / Group / Face of Policy(s)
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Do you have additional questions about insurance you would like us to add to our next meeting agenda? How much do I need? When should I drop my life insurance? When should I get more? Do I need cash value policy?
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Please verify that you are human* This field is required.
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