Medical Pre-Screening

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.

Your name and contact information is never given to the carriers when requesting a pre-screen. Read our Medical Conditions page to see how health conditions can govern the final outcome of your life insurance application. Feel free to use our quote engine to review the best Term life insurance quotes & comparisons. We recommend reading our blog post concerning the life insurance application process.

• 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:
• Phone
  This field is for validation purposes and should be left unchanged.