LIFE INSURANCE - APPLICATION
Client Information
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I agree to the SMS consent and Terms & Conditions described above.
Primary Insured - First Name* / Last Name*
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First Name
Last Name
Primary Insured Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth* (MM/DD/YYYY)
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email*
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example@example.com
Phone Number* (000) 000-0000
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Format: (000) 000-0000.
Place of Birth* - City / State or Country
Social Security Number*
Driver's License Number*
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Driver's License Expiration* (MM/DD/YYYY)
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender*
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Male
Female
Marital Status*
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Married
Single
Divorced
Widowed
Height* (ft/in or total inches)
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Weight* (100-600 lbs)
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Employer*
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Years at Current Employer?
Occupation / Title*
Yearly Gross Income*
Current Life Insurance Inforce - Coverage Amount
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UNDERWRITING PRE-SCREENER
Life Insurance Goals & Coverage Request
If an insurance agent is assisting you, what is their name?
Please Select
Not Sure / No One Yet
Lisann Taylor
Brett Garner
John Hadder
Bo Davenport
Dionne Thomas
What do you want life insurance to do for you? Select all that apply.
Help my family with funeral expenses and some financial support
Help my family be financially supported for years after I pass
Cover my mortgage
I am not sure what I want from it
Other
Additional details about what is most important to you:
Life Insurance Death Benefit Requested*Enter the exact amount requested, from a Minimum of $5,000 and up to $50,000,000.
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Life Insurance Coverage Type Requested*
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Term Life
Whole Life
Universal Life
Index Universal Life
Final Expense
Other
Primary Beneficiary Information
Primary Beneficiary Name
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First Name
Last Name
Relationship to Primary Beneficiary*
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Primary Beneficiary Phone Number*
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Format: (000) 000-0000.
Primary Beneficiary Address*
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Would you like to add a Secondary Beneficiary?
Yes
No
If Yes, please include information below:Name, address, phone number, email address, and relationship to you.
Lifestyle Habits
Tobacco Use:* (Tobacco and nicotine products include cigarettes, cigars, pipe tobacco, chewing tobacco, dip/snuff, snus, hookah/shisha, heated tobacco, nicotine pouches, e-cigarettes, vapes, and e-liquids.)
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Yes
No
Alcohol Use:* ( Alcohol use includes beer, wine, liquor/spirits, cocktails, and other alcoholic beverages.)
Yes
No
If yes on Alcohol Usage, please provide the type of alcohol, average number of drinks consumed, and frequency (daily, weekly, or monthly)
Marijuana Use:*
Yes
No
If yes on Marijuanna Usage, please indicate the type (smoked, vaped, edible, or other), purpose (medical or recreational), frequency of use, and date of last use.
Controlled Substances or Illicit Drugs Use:* ( The use of illegal drugs or controlled substances without a valid prescription, including substances such as cocaine, heroin, methamphetamine, non-prescribed opioids or fentanyl, hallucinogens, and other illegal or misused drugs.)
Yes
No
If yes on Controlled Substances or Illicit Drug Usage, please provide the substance used, frequency, date of last use, and any treatment or counseling received.
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UNDERWRITING PRE-SCREENER
Family History
Is there a history of cardiovascular disease, cerebrovascular disease (including stroke), or cancer diagnosed before age 60 in any first-degree relatives (parents or siblings)?*
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Yes
No
If Yes, please provide relationship, condition, and age at diagnosis:
Are your parents living? Please provide details below:Father: age/living status/health issues. Mother: age/living status/health issues.
Number of Siblings
Sibling detailsFor each sibling, list age, whether living (Y/N), and any medical issues.
Blood Pressure and Cholesterol
Are you currently taking any medication for blood pressure?*
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Yes
No
Latest Blood Pressure Reading*
Are you currently taking any medication to lower cholesterol?*
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Yes
No
Latest Total Cholesterol*
Are you currently taking any medication for diabetes, prediabetes, or elevated blood sugar?*
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Yes
No
If Yes to diabetes, prediabetes, or elevated blood sugar, please provide the type of diabetes, date diagnosed, most recent A1C, medications or insulin used, and whether you have experienced any diabetes-related complications.
Are you currently taking any other prescription or maintenance medications?*
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Yes
No
Please list any prescription or maintenance medications you are currently taking that have not already been mentioned, including the medication name, dosage, frequency, and the condition or reason for taking it.*
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UNDERWRITING PRE-SCREENER
In the past 5 years have you or do you intend to participate in any of the activities listed?*
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Flying
Racing
Sky Diving
Scuba Diving
Other
None
If applicable, provide details:
Citizenship / Residency / Travel
US Citizen:*
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Yes
No
Any future plans to live or travel outside the USA?*
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Yes
No
If Yes, list country/countries, duration, and purpose:
Driving / Criminal Background History
Criminal Background: Any known felony or misdemeanor convictions?*
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Yes
No
Unknown
Within the past 10 years, has there been any motor vehicle-related incidents?*
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Moving Violation
Reckless Driving
DWI or DUI
License Suspension
License Revoked
None
If applicable, provide dates and details:
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UNDERWRITING PRE-SCREENER
Medical History
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UNDERWRITING PRE-SCREENER
Confidential - For underwriting pre-screening
Ever been diagnosed with, advised of, or received treatment for any of the medical conditions listed below? Select all that apply.*
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Alcohol abuse
Alzheimer's / dementia / cognitive impairment
Asthma
Cancer
Cirrhosis
COPD
Coronary artery / cerebrovascular disease
Heart disease / heart conditions
Crohn's disease
Anxiety
Depression
ADD / ADHD
Diabetes
Drug abuse
AIDS / HIV
Epilepsy
Heart murmur / valve disease
Hepatitis
Irregular heartbeat / palpitations
Kidney disease
Lupus
Multiple sclerosis
Peripheral vascular disease
Rheumatoid arthritis
Sleep apnea
Stroke
Other
None
Medical History - Please list any additional details:*For any condition selected, provide diagnosis, date, treatment/surgery, current status, and physician details.
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UNDERWRITING PRE-SCREENER
Confidential - For underwriting pre-screening
Primary Care Physician / Health Care Provider*Name & address, how long you have been a patient, and any diagnoses.
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Date of Last Dr Visit* (MM/DD/YYYY)
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Last Dr Visit*
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Please include any other information about your health, medications, diagnoses, etc:
Quote Information
Ever been declined for life insurance?*
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Yes
No
Unknown
Choose your application process preference*
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Full Underwriting - In-home insurance exam; typically best rates and longest process.
EZ Underwriting - No in-home exam; typically higher rates and quicker issue.
Simplified or Guaranteed Issue - No exams; quick process; commonly used for Final Expense.
Additional Notes / Underwriting Details
Communication Consent & Terms
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UNDERWRITING PRE-SCREENER
Confidential - For underwriting pre-screening
Pre-Screener Acknowledgment
Information provided is for preliminary underwriting review and may require verification or additional information.
Final eligibility, classification, rates, and coverage are determined by the applicable insurance carrier.
I confirm the information entered is complete and accurate to the best of my knowledge.
Complete all required (*) fields. This pre-screener is not an application for insurance or an offer of coverage.
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