Disability Insurance Health Prescreen Form

Not an application for insurance. This Prescreen Form is used exclusively to gather specific information on a proposed insured’s medical history and other factors that may impact underwriting and rating classifications.

MM slash DD slash YYYY
Untitled
Sex
Marital Status

HEALTH

VERY IMPORTANT: Over 40% of disability cases are rated, declined or carry exclusions. Please answer honestly. Do you have a history of:

Neck or back disorders
Depression, anxiety or other mental disorders
Diabetes
Sleep Apnea
Cardiac conditions
Cancer
Other known health conditions for which treatment was needed

OCCUPATION

Government employee?
Work from home?
Business owner?

EXISTING DISABILITY INSURANCE

Will it be replaced?
Will it be replaced?

PROPOSED DISABILITY INSURANCE

Desired Elimination Period (check one)
Desired Benefit Period (check one)
Optional Riders (if available)
Call Email Claims Payments
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