Individual Underwriting Pre-screen
                      Fields in Red are Required

Carrier/Plan:
 
 

Agent Information
Name:
 
E-mail:
 
Phone: Fax: State:
     

Applicant's Information

Individual Name:
 
Occupation:
 
Age: Sex: Height: Weight: Smoker:
         
Spouse's Name:
Occupation:
Age: Sex: Height: Weight: Smoker:
Medical Condition/Diagnosis: Treatment/Medication:
 Include how often medication is refilled
   
Home Office Use Only
 Proposed Underwriting Action:		  
Best Case: Worst Case:
Underwriter: Date:
Disclaimer
·
 Please be advised this is an estimate based on the information supplied.
·
 This pre-screen is not a guarantee of coverage.
·
 This quote is not intended to replace the medical underwriting process.
·
 Any census change and medical information not disclosed may alter this pre-screen.