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.
Contact Name:
Email:
Phone Number:
ZipCode:
Have you had insurance within the last 63 days?
Employment Status:
Do you currently have health insurance?
Have you been offered COBRA Insurance?
Date you need coverage:
Reason needing insurance:
Initials
Age
Gender
Ht
Wt
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
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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TennHealth Insurance Services
210 Hidden Hills Cir
Lexington TN 38351