Life 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
Marital Status


Do you currently use tobacco in any form (cigarettes, cigars, chewing tobacco, etc.)?
Are you a past tobacco user?
Any type of Marijuana ?

Driving Record

Have you ever been arrested for driving under the influence of alcohol or drugs?

Medical Impairments and History

Family History

If Yes, Relation to you?

Occupation and Family

Do you work?
Do you have dependents?

Other Coverage

Do you have other life insurance (e.g., group life insurance through work or another individual policy?
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