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Underwriting Pre-Screener
Agent Information
Agent Name
*
First
Last
Email
*
Business Phone
*
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Fax
Client Information
Applicant's Name
*
First
Last
State of Sale
*
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Alaska
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District of Columbia
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Date of Birth or Age
*
Gender
*
Male
Female
Height
*
Not Sure
4' 1"
4' 2"
4' 3"
4' 4"
4' 5"
4' 6"
4' 7"
4' 8"
4' 9"
4' 10"
4' 11"
5'
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6'
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
6' 6"
6' 7"
6' 8"
6' 9"
6' 10"
6' 11"
7'
7' 1"
7' 2"
7' 3"
7' 4"
Weight
*
Please enter a number from
100
to
600
.
Have you ever been declined for life insurance?
*
Yes
No
Not Sure
Reason for Decline?
*
Have you ever filed bankruptcy?
*
Yes
No
Not Sure
Has the bankruptcy been discharged or resolved?
*
Yes
No
Do you use tobacco or vape?
*
Yes
No
Type of Tobacco
*
Cigarette
Cigar
Chew or Snuff
Nicotine Patch
Pipe
Vape
Do you use marijuana?
*
Yes
No
Frequency and type of marijuana use
*
Have you had a DUI or DWI in the last 5 years?
*
Yes
No
Date and deatils of DUI or DWI
*
Are you taking any medications?
*
Yes
No
List medications
*
Quote Information
Plan Type
*
Term
Permanent (Whole Life or Universal Life)
Final Expense
Choose your application process preference
*
Full Underwriting - My client is okay with an in-home insurance exam. Full underwriting offers the best rates but takes the longest.
EZ Underwriting - No in-home exam needed. Higher rates but issued quickly.
Simplified or Guaranteed Issue - No exams needed. Quick. Perfect for Final Expense.
Death Benefit Amount
*
Please enter a number from
5000
to
50000000
.
Additional
Additional comments or health concerns?
