Underwriting Pre-Screen Form
Purpose of this form:  Each insurance company has different guidelines in regards to approving a health insurance policy.  This form is a
tool to allow your agent to look at your health conditions without having to fill out a formal application for coverage.  We will research the
different companies guidelines and report to you which company is most likely to offer you coverage at the best rate.  

To request a pre-screen, please fill out the form below.   Your agent will research your medical conditions, contact different insurance
carriers and provide you with a report of the results.
Contact Name:
Email:
Phone Number:
ZipCode:
Employment Status:
Reason needing insurance:
Have you had insurance within the last 63 days?
Your current Insurance Company?
Have you been offered COBRA Insurance?
Date you need coverage:
Have you been declined for coverage?
If "Yes" which company declined you & reason for decline.
Household Information           (Optional - to be used to see if you qualify for government plans)   
Number of people in your household:
Household Yearly Income:
Do you own or rent your home:
Personal Information
Insured
Initials
Age
 Height
 Weight
Gender
Medical Information
Please list  medical conditions and prescriptions currently taking such as High Blood Pressure, Diabetes, Heart Conditions,
Allergies, Depression   The more information you list, the more accurate your report will be.
Medical Condition (s)
 Medication
Treatment Details and appx dates
High Cholesterol/Lipid disorders:
 Blood pressure reading
Total Cholesterol
LDL Cholest
HDL Cholest
Triglycerides
Medication
High Blood Pressure/Hypertension
 Last 3 blood pressure
readings
Medication
Additional Comments
Describe your unique situation that may affect you being able to obtain coverage.  If there is a maximum budget, list here.
By submitting this form, your request will be processed by a Tennessee Health Insurance Services licensed insurance agent.   You
may be contacted by your agent to clarify information needed to provide your pre-screen report.  This is not an application for
medical insurance.  Any offer of insurance will require completion of an medical application for the insurance carrier you choose.
  • There is no charge for this service.
  • This is not a medical application.
  • No payment information is asked for.
  • Information submitted is not shared with anyone
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