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Pre-Screening Insurance Quote Form
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PLEASE READ FIRST

Congratulations on taking the first step to securing your and your family’s future!

To ensure a smooth process, please have the following information ready during our scheduled meeting:

Social Security Number (SSN)
Bank name, routing and account number
Details of any existing insurance policies

Important: This form must be completed for each individual aged 18 and older who is requesting a quote.

Rest assured, all information you provide will be kept strictly confidential and used solely for the purpose of preparing your personalized insurance quote.

Thank you for your trust—we look forward to helping you protect what matters most!

Full Legal Name (First and Last Name) *
Date of Birth *
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/
DD
/
YYYY
Gender *
Martial Status *
What is your complete address, including city, state, and ZIP code? *
Phone Number (123-456-7890) *
Email (me@example.com) *
Please provide your driver's license or state identification number including the issued state.
Height (An approximation is perfectly fine.) *
Weight  (An approximation is perfectly fine.) *
 Are you a Tobacco Smoker or Non-Smoker? (If you use marijuana or vape, please specify below. This WILL NOT affect your eligibility for coverage.)  
Do you currently have any private life insurance policies outside of your employer-provided coverage? If yes, is it a Whole Life or Term Policy?  
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Do you have ANY medical diagnosis? If so, list every diagnosis below.  *
Do you have ANY mental health diagnosis? If so, list every diagnosis below.
Have you been prescribed any medications in the past ten years? If yes, please list all medications below, including those you are no longer taking.  
Have you been hospitalized within the past 12 months? If yes, please provide the reason for the hospitalization.  
Have you been convicted of a felony, are you currently awaiting trial for a felony, or have you experienced any incarceration within the past 10 years?  

Do you currently receive any disability benefits?

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Do you have a high-risk occupation (e.g., military, law enforcement, frequent occupational travel, etc.)? If yes, please specify your job role

Have you been convicted of three (3) or more moving violations within the past five (5) years?  
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 Have you had any DUIs, DWIs, reckless driving incidents, or moving violations within the past 10 years?  
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What type of insurance policy are you looking for?
  What is a comfortable budget for insurance coverage—an amount that wouldn’t place any financial strain on you?
Do you have any children under the age of 18 you would like to cover? If yes, please provide their names and dates of birth.  
Thank You for Completing the Prescreening Form!

We appreciate your time and effort in providing these details. This information helps us tailor the best life insurance options to meet your needs. One of our licensed agents will review your responses and reach out to discuss your coverage options.

If you have any additional questions or need further assistance, please don’t hesitate to contact us. We’re here to help you secure peace of mind for yourself and your loved ones.

Your Elite Life Team
Contact Us: solutions@jpelite.biz
Website: jpelite.biz

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