Insurance Underwriting Pre-Screen Form
Please complete this pre-screening form to help us assess your eligibility for insurance coverage, including long-term care considerations.
Client Information
Applicant State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Advisor Name
*
Applicant Name
*
First Name
Last Name
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General Information
Gender
*
Male
Female
Marital Status
*
Single
Married
Occupation
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Height
*
(ex. 5'6")
Weight
*
(ex. 175 lb.)
In the past 5 years, have you used any Tobacco/Nicotine products?
*
Yes
No
Type, Frequency, Amount of Use, and Date of last use.
Do you have any surgeries scheduled that have not yet been performed?
*
Yes
No
If yes, date, surgery details, and any additional follow-ups needed.
Have you completed an annual physical within the last 2 years?
*
Provide the date (01/2025)
Were you previously declined for life insurance or LTC insurance?
*
Yes (If yes, please send a copy of the decline letter to your advisor)
No
Have you ever been convicted of a felony?
*
Yes
No
Please provide dates and details.
*
Provide the date (01/2025)
Are you currently receiving any of the following disability or assistance benefits?
*
Social Security Disability
VA Disability
Private Disability
Medicaid
None of the above
What is your disability rating?
Please list all medical conditions with date of diagnosis.
*
Medication, Dose, and Treatment For (Put each Medication on its own line)
*
Have you received any other treatments such as chiropractic care, physical therapy, or counseling? If yes, please describe the type of treatment, reason, and dates.
*
Have you had any other medical events, such as hospitalizations or emergency room visits? If yes, please provide details, including the reason, location, and dates.
*
Cardiac/Heart (Atrial Fibrillation, Coronary artery Disease, or Valvular Heart Disease required Additional Detials)
Have you had a cardiac event?
*
Yes
No
Diagnosis and Date Diagnosed (mm/yy)
Dates and Results of Most Recent Cardiac Testing EKG, Catheterization, Echocardiogram, Stress Test
Provide Details of Any Current Blockages or Recent Symptoms (shortness of breath, chest pains, fatigue, lightheadedness, other)
Select All That Apply
Stroke
TIA
Cardiomyopathy
Diabetes
Peripheral Vascular Disease
Congestive Heart Failure
Any other condition of the heart
Provide Dates and Details
Atrial Fibrillation - Treatment (select all that apply)
Medication
Ablation
Cardioversion
Pacemaker
Defibrillator
Provide Dates and Details (include dates and medications)
Coronary Artery Disease - Treatment (select all that apply)
Medication
Angioplasty
Stenting
Bypass Surgery
Any other heart surgery
Any left main involvment
History of Heart Attack?
Yes
No
If yes, provide details (include dates, medications, vessels involved and number of stents and/or vessels bypassed)
Valvular Heart Disease - Which valve(s) (Aortic, Mitral, other)
Treatment (select all that apply)
Medication
Surgery (repair or valve replacement)
Provide Dates and Details
Cancer - Complete for all (Breast, Prostate, Leukemia, and Lymphoma Require Additional Details)
Have you been diagnosed with cancer? (If no, please skip down to Diabetes)
*
Yes
No
Diagnosis, location, date of diagnosis (mm/yy)
Stage, Grade, Type, and Size of Tumor
Lymph Node Involvement or Spread to Any Other Organs
Treatment (select all that apply)
Surgery
Chemo
Radiation
Other
Date Last Treated (mm/yy)
Any Recurrence or Additional/Other Cancer
Yes
No
If yes, please provide details.
Breast Cancer
Select Type
Ductal
Tubular
Lobular
Mucoid
Papillary
Medullary
Estrogen Receptor
Positive
Negative
Unknown
Prostate Cancer
Gleason Score, PSA at Time of Diagnosis, Current PSA
Treatment (select all that apply)
Surgery
Chemo
Radiation
Active Surveillance
Watchful Waiting
Other
Date Last Treated (mm/yy)
Ex. 11/2024
Leukemia
Select Type
Acute Lymphoid (lymphoblastic) Leukemia (ALL)
Acute Myeloid (myelogenous leukemia) (AML)
Chronic Lymphocytic (CLL)
Hairy Cell Leukemia
Chronic Myeloid Leukemia (CML)
Age at Diagnosis
Ex. 60
Lymphoma
Select Type
Hodgkin's
Non-Hodgkin's (Select subtype)
MALT Lymphomas
MALToma's
Extra Nodal Marginal Zone B-Cell
Follicular
Transformed Follicular
Nodal Marginal Zone B-Cell
Diffuse Large B-Cell
Burkitt
Mantle Cell
Peripheral T-Cell
Other High-Grade Lymphoma
Cutaneous Lymphoma
Mycosis Fungoides
Sezary Syndrome
Adult T-Cell Lymphoma/Leukemia
Diabetes
Do you have or have had diabetes?
*
Yes
No
Date of Diagnosis (mm/yy)
Date Last Tested A1C (mm/yy)
A1C Result
Names and Dosage of Medications
Type of Diabetes
Type I
Type II
Select All That Apply
Retinopathy (Background)
Retinopathy (Proliferative)
Heart Disease
Neuropathy
Kidney Disease
Cerebrovascular
Peripheral Vascular Disease
Skin Ulcers
Amputations
Urine Protein/Microalbumin
Provide Dates and Details
Mental/Nervous
Have you ever been diagnosed with a behavioral or mental health condition?
*
Yes
No
Select all that apply
Anxiety
Depression
Bipolar
ADD/ADHD
PTSD
Date Diagnosed (mm/yy)
Medication Dosage and Any Other Treatment
Any hospitalizations or ER visits?
Yes
No
Provide Details (including dates and length of stay)
Musculoskeletal
Have you ever been diagnosed with a musculoskeletal condition?
*
Yes
No
Diagnosis and Date of Diagnosis (mm/yy)
Treatment
Medications
Injections
Injection Type, Frequency, and Last Injection (if applicable)
Physical Therapy
Yes
No
Use of Any Assistive Devices
Yes
No
Any Functional Limitations
Yes
No
Surgery Recommended or Planned
Yes
No
If YES to any of the above, provide complete details
Osteoporosis
Have you ever been diagnosed with osteoporosis by a healthcare professional?
*
Yes
No
Date of last bone density (mm/yy) and provide actual T-Scores
Any Falls/Broken Bones/Fractures
Yes
No
If yes, provide date and location
Treatment
Respiratory/Asthma/COPD/Sleep Apnea
Have you ever been diagnosed with Respiratory/Asthma/COPD/Sleep Apnea?
*
Yes
No
Diagnosis, date of diagnosis (mm/yy), and treatment
Any prior tobacco use?
Yes
No
If Yes, date last used (mm/yy)
Hospitalizations, ER visits or any limitations due to shortness of breath
Yes
No
If Yes, provide details
Any use of supplemental oxygen?
Yes
No
Stroke/TIA
Have you ever been diagnosed with a stroke or transient ischemic attack (TIA)?
*
Yes
No
Select all that apply
Stroke (Single)
Stroke (Multiple)
TIA (Single)
TIA (Multiple)
Date(s), Diagnosed (mm/yy), Treatment
List any residuals
Submit Pre-Screen
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