Medical Pre-Screening

This is a secure digital form where your information is completely safe and confidential. Please complete these fields with your detailed information so we may review your case and find the most applicable life insurance company for your given health history. This will allow us to secure the lowest rates for you. Please be as detailed as possible in order for us to receive accurate rates from the multiple carriers we request projected rates from. Medical Pre-Screening is a very important step in securing the best life insurance plan for the least amount of money. Having any health conditions could affect the final rates of your application and we want to limit the impact they may have on your premium. 

The primary purpose of a medical pre-screen is to predetermine what life insurance company will offer you the lowest premiums.

This is a simple and secure inquiry that helps to eliminate unforeseen changes in your health classification once your application is approved.

Your information is always secure and shared with no one for any reason.

Even the life insurance companies themselves will have no knowledge of your identity.

Once this form is completed, all of the work is done entirely by your agent.

• First Name:*
• Last Name:*
• Email*
• Phone*
• State:*
• Zip Code:*
• Gender:*
  • Male
  • Female
• Date of Birth*
• Height:*
• Weight:*
• Nicotine or Tobacco Use?*
  • Yes
  • No
• Please explain usage*
• Coverage Amount?*
• Term Length (in years):*
• Medical Conditions (please be as detailed as possible):
• Prescriptions:
• Comments:
• Email
  This field is for validation purposes and should be left unchanged.

Medical conditions otherwise known as health conditions are pre-existing medical problems. These could be conditions such as High Cholesterol, Hypertension (high blood pressure), Diabetes, Heart Conditions, Obesity (overweight), Cancer, Anxiety, Depression, Epilepsy, Kidney Disease, Strokes, Asthma and many others.