Disability & 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.

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Cost of Disability Income (DI) Insurance: Some clients are surprised by the cost of quality disability insurance. A general rule of thumb is to be fully/properly insured, a quality individual disability policy will cost in the range of 2-4% of your annual income. Example: Annual income of $100,000 will require an annual premium in the range of $2,000-$4,000/yr. If such premiums don't match your budget, we can provide some options to lower the premium and coverage, so please let us know your budget if 2-4% is too expensive.

CLIENT INFO

Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Marital Status(Required)

Married

Live with partner

Single

Did someone refer you?(Required)

Yes

Who referred you?

Are you a U.S. citizen?(Required)

Yes

Are you a permanent resident?(Required)

Yes

Do you have a specific max monthly budget for disability income insurance?(Required)

Yes

Unsure

Some clients are surprised by the cost of quality disability insurance. A general rule of thumb is to be fully/properly insured, a quality individual disability policy will cost in the range of 2-4% of your annual income. Example: Annual income of $100,000 will require an annual premium in the range of $2,000-$4,000/yr. If such premiums don't match your budget, we can provide some options to lower the premium and coverage, so please let us know your budget if 2-4% is too expensive.

What's your max monthly budget?(Required)

HEALTH

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

Height

Weight - Pounds(Required)

TOBACCO/MARIJUANA

Do you currently use OR were you a previous user of marijuana or tobacco in any form (cigarettes, cigars, chewing tobacco, e-cigs, etc)?(Required)

Yes

What form?(Required)

Tobacco - smoke

Chewing Tobacco

Marijuana

E-Cigarettes

Cessation Products

Other

Do you still use?(Required)

Yes

When did you quit?(Required)

DIAGNOSES, MEDICATIONS, TREATMENTS

Neck or back disorders?(Required)

Yes

Provide details:

Do you go to a chiropractor?(Required)

Yes

Provide details:

Depression, anxiety or other mental disorders?(Required)

Yes

Provide details:(Required)

Diabetes?(Required)

Yes

Approx. date of diagnosis:(Required)

Do you use insulin?(Required)

Yes

How many units per day?(Required)

What was your last A1C reading?(Required)

Sleep Apnea?(Required)

Yes

Do you use a CPAP machine nightly?(Required)

Yes

How long have you been using a CPAP machine?

What's your apnea-hypopnea index?

Cardiac conditions?(Required)

Yes

Provide details:(Required)

Have you ever had cancer?(Required)

Yes

Type (note if metastatic cancer) and stage(Required)

Treatment and date of last treatment(Required)

If prostate cancer, provide PSA levels

Other important details to any YES answers:

Any notable persistent fatigue?(Required)

Yes

Provide details:(Required)

Surgeries or injuries?(Required)

Yes

Provide details:(Required)

Other known health conditions for which treatment was needed?(Required)

Yes

Provide details:(Required)

Are you taking or have you taken any prescription medication(s) within the past 3 years OR are you currently taking any over-the-counter medications?(Required)

Yes

Provide details on medications:(Required)

Medication Name

Purpose

Approx. Date First Prescribed

Frequency

Dosage

Date of Last Dosage Change

Type N/A if not applicable.

Do you have any test results that are pending?(Required)

Yes

Provide details:(Required)

Have you had any test results in the past 2 years that were abnormal or unfavorable?(Required)

Yes

Provide details:(Required)

When was the last time you visited a doctor and/or medical facility? Provide details:(Required)

OCCUPATION & FAMILY

Do you have dependents?(Required)

Yes

How many kids?(Required)

Ages of kids?(Required)

Name of employer(Required)

Job title(Required)

How long at current employer?(Required)

How many years in this occupation?(Required)

Daily duties - please be specific(Required)

Government employee?(Required)

Yes

Work from home?(Required)

Yes

% of travel / % no travel(Required)

Business owner?(Required)

Yes

Monthly business expense amount?(Required)

How long have you been self-employed?(Required)

How many full-time employees?(Required)

THIS YEAR'S Expected Pre-Tax W-2 and 1099 earnings (if self-employed: after expenses and before taxes)(Required)

LAST YEAR'S Pre-Tax W-2 and 1099 earnings (if self-employed: after expenses and before taxes)(Required)

2 YEAR'S AGO Pre-Tax W-2 and 1099 earnings (if self-employed: after expenses and before taxes)(Required)

DISABILITY INCOME INSURANCE

Have you been previously declined for disability insurance?(Required)

Yes

Provide details:(Required)

Existing Disability Insurance

Do you have existing GROUP disability insurance?(Required)

Yes

% of income covered(Required)

Monthly max/cap(Required)

Elimination Period (Waiting Period)(Required)

Who pays the premium?(Required)

Employer

Employee (me)

Benefit Period(Required)

Will it be replaced?(Required)

Yes

Do you have existing INDIVIDUAL disability insurance?(Required)

Yes

Monthly benefit(Required)

Elimination Period(Required)

Benefit Period(Required)

Will it be replaced?(Required)

Yes

Proposed Disability Insurance

Desired Monthly Benefit Amount(Required)

Max eligible for

Other

Desired Elimination Period(Required)

30 day

60 day

90 day

180 day

365 day

TBD

Desired Benefit Period(Required)

2 yr

5 yr

10 yr

To age 65

To age 67

To age 70

TBD

Optional Riders (if available)

Residual (Partial)

Cost of Living Adjustment

Catastrophic

Future Increase Option

Own Occupation

Student Loan Repayment

TBD

LIFE INSURANCE

Have you been previously declined for life insurance?(Required)

Yes

Provide details:(Required)

Do you have existing GROUP life insurance?(Required)

Yes

List death benefit, term, and details:(Required)

Do you have existing individual life insurance?(Required)

Yes

List death benefit, term, and details:(Required)

Will it be replaced?(Required)

Yes

Life Insurance Desired

Death benefit amount(Required)

Term length(Required)

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