Underwriting Pre-Screen Form
To request a pre-screen, please fill out the form below. Your agent will research your medical conditions, contact
different insurance carriers and contact you with a report of the results.
Privacy Statement
Contact Name:
Email:
Phone Number:
ZipCode:
Have you had insurance within the last 63 days?
Select
Yes
No
Employment Status:
Select
Self Employed
Employed - Group Plan Available
Employed - Group Plan Not Available
Laid off
Unemployed
Disabled
In School
Do you currently have health insurance?
No Insurance
COBRA
Group Insurance
Aetna
Bluecross Blueshield of Tennessee
TennCare
UnitedHealth
Celtic
Farm Bureau / TRH
NASE/Mega Life
Midwest of Tennessee
Golden Rule
Humana
United American
Fortis
World Insurance Co
Other
Non-Insurance Discount Card
Have you been offered COBRA Insurance?
Select
Yes
No
Date you need coverage:
Reason needing insurance:
Select
Losing COBRA
Don't have insurance now.
Looking for better rates
Loosing Group Coverage
Needing policy for child only
Family coverage on Group Plan too expensive
Needing coverage to help pay for medication
Other
Initials
Age
Gender
Ht
Wt
M
F
Non-Tobacco
Tobacco user
M
F
Non-Tobacco
Tobacco user
M
F
M
F
M
F
Medical Information
Please list medical conditions and prescriptions currently taking such as High Blood Pressure, Diabetes, Heart Conditions,
Allergies, Depression (This will allow us to get you a more accurate report)
Family Member
Diagnosis/Condition
Medication
Details
Primary Applicant
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Primary Applicant
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Primary Applicant
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Primary Applicant
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Primary Applicant
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
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.
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