Life Insurance Pre-Screening Questionnaire
Please complete the below questions so we can provide a more accurate quote
Name
*
First
Last
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Height
*
Feet and Inches
Weight
*
Weight in lbs
How much coverage do you need and how long do you need coverage to last?
*
Do you have any history (or current use) of tobacco or recreational drugs? If yes, please specify:
Please list any medications you are currently taking, including the name, dosage, frequency, and condition treated.
In the past 10 years, have you been treated for any of the following?
Cancer, heart disease, diabetes, stroke, epilepsy, or dementia?
Disorder or disease of liver, kidneys, pancreas or lungs?
Mental or nervous system disorder, including depression or anxiety?
Major surgeries?
Alcoholism or drug use?
If yes to any of the above, please provide details.
Have any immediate family members (parents or siblings) been diagnosed with heart disease, stroke, diabetes, or cancer before the age of 60?
Yes
No
If yes to the above, please specify.
In the last 10 years, have you had any DUI, OWI, or anything beyond minor moving violations?
Yes
No
If yes to the above, please specify.
Do you have a spouse, children, or other dependents currently relying on you for income?
Yes
No
If you are currently working, please specify your occupation and approximate annual income.
What is the total amount of all debts you have? (Mortgage, student loans, vehicle loans, etc.)
Do you have any other life insurance coverage currently in effect? If yes, please provide details.
Is there any information you would like to provide that wasn't asked above?
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