Life Insurance Pre-Qualification

About you

The basics every carrier needs to open a file.

First name *

Last name *

Email *

Phone *

Date of birth *

Age *

Gender * as carriers record it

Last 4 of SSN *

Street address *

City *

State *

ZIP *

State you were born in

Driver license number & state optional

Mother's maiden name optional

Primary care physician name & office — optional

Coverage & income

How premiums would be drafted, and what you already have in place.

Type of income *

Preferred draft frequency *

Preferred draft day of month

Do you have an existing life insurance policy? *

No Yes

Current carrier & coverage amount

Beneficiaries

Who receives the benefit. Contingent beneficiaries are the backup if the primary can't receive it.

Primary beneficiary — full name *

Relationship *

Primary beneficiary — date of birth

Second primary beneficiary optional

Relationship

Contingent beneficiary optional

Relationship

Second contingent optional

Relationship

Health — the essentials

Height, weight and tobacco move your rate class more than almost anything else on this form.

Height *

Weight (lbs) *

Do you currently use tobacco or nicotine? *

No Yes

What type, and how often?

Have you used tobacco or nicotine in the last 12 months? *

No Yes

Hospitalizations & surgeries

Recent procedures often decide which carrier can move now and which needs to wait.

Any surgeries or hospitalizations in the last 12 months? *

No Yes

List each one — type, date, reason, outcome

Are you currently awaiting any surgery or procedure? *

No Yes

What procedure, and expected date?

Diabetes

Carriers vary widely here. Good numbers can still earn a strong rate class.

Have you been diagnosed with diabetes? *

No Yes

Age diagnosed

Do you use insulin?

Age started insulin

Most recent A1C

Most recent fasting sugar reading

Any complications?

If yes, describe

Heart & cardiovascular

Dates matter as much as diagnoses — many carriers price on how long ago something happened.

Have you ever had a heart attack? *

No Yes

Date of heart attack

Have you been diagnosed with heart disease? *

No Yes

Have you had heart surgery?

No Yes

Date of surgery

Pacemaker?

If yes, date installed

Defibrillator / ICD?

If yes, date installed

AFib or irregular rhythm?

If yes, last occurrence

Congestive heart failure?

If yes, last occurrence

Stroke

Includes TIAs — the short ones that resolve on their own still count to an underwriter.

Have you ever had a stroke or TIA? *

No Yes

Date of last occurrence

Any lasting effects or disabilities?

Cancer

Time since last treatment is usually the deciding factor, not the diagnosis itself.

Have you ever been diagnosed with cancer? *

No Yes

Type of cancer

Date of last treatment

Currently in remission?

Lung & respiratory

Treated sleep apnea is viewed very differently from untreated — worth being exact here.

Diagnosed with COPD or any lung disease? *

No Yes

Do you use oxygen?

If yes, how often

Do you have sleep apnea? *

No Yes

Date diagnosed

CPAP — and how often?

Current inhalers & respiratory medications — list all

Medications

Carriers pull a prescription history anyway — listing them yourself keeps everything lined up and avoids delays.

Current medications — name, dosage, and what it's for *

Medications from the past 3–5 years you're no longer taking

Last thing

Anything you'd want me to know before I start shopping carriers.

Anything else relevant to your health or coverage needs

How did you hear about McDonald Wealth Management? *

That's everything.

I'll review this, run it across the carriers you qualify for, and come back with real options — not one company's answer.

Your information stays on our own secure server. Never sold.

Got it — thank you.

I'll go through this personally and reach out to walk you through what each carrier says. Go ahead and grab a time that works for you.

Book my consultation →

About you

Coverage & income

Beneficiaries

Health — the essentials

Hospitalizations & surgeries

Diabetes

Heart & cardiovascular

Stroke

Cancer

Lung & respiratory

Other conditions

Medications

Last thing

That's everything.

Got it — thank you.