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 provide 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:
Have you been declined for coverage?
If "Yes" which company declined you?
Reason needing insurance:
Insured
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   The more information you list, the more accurate your report will be.
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
Other 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.
  • Information submitted is not shared with anyone
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Health Insurance Plans for Tennessee