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Life Insurance Quote
Hi there, Congratulations on taking the first step in securing your family's future!
28
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1
How did you hear about us?
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Google, Yelp, Facebook, Instagram, Radio Ad, Friend, Agent etc.
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2
Who is the agent that referred you?
If applicable
Alexandra Cruz
Dagoberto Cruz
Deilis Carrazana-Galan
Glenda Mendez
Joshua Amador
Mariapaula Vega
Marina Guadamuz
Robert Bonilla
Other
Alexandra Cruz
Dagoberto Cruz
Deilis Carrazana-Galan
Glenda Mendez
Joshua Amador
Mariapaula Vega
Marina Guadamuz
Robert Bonilla
Other
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3
What's your name?
*
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Your personal information will ALWAYS be confidential & secured!
First Name
Middle Name
Last Name
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4
When is your birthday?
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/
Date
Month
Day
Year
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5
What's your gender?
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M
F
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6
Do you smoke? (Tobacco, E-Cigarette, Cannabis)
*
This field is required.
No, I do not smoke
Yes, Rarely (1-2x / Month)
Yes, Occasionally (4-5x / Month)
Yes, Frequently (6x or more / Month)
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7
What's your marital status?
*
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Single
Married
Divorced
Domestic Partner
Separated
Widowed
Single
Married
Divorced
Domestic Partner
Separated
Widowed
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8
How tall are you?
*
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Ft, In
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9
How much do you currently weigh?
*
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lbs
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10
What is your current employment status?
*
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Employed
Full-time Student
Homemaker
Unemployed
Retired
Employed
Full-time Student
Homemaker
Unemployed
Retired
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11
What do you do for a living?
*
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Please be specific
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12
What's your annual income?
*
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Your income
Ex: $50,000
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13
What's your annual household income?
*
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Combined family income
Ex: $75,000
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14
What's your estimated net worth/total assets?
*
This field is required.
This helps us determine how much coverage you need! (Assets - Debts/Liabilities = Net Worth)
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15
What is the primary reason you are seeking coverage?
*
This field is required.
Select all that apply
Business Purposes
College Expenses
Death Benefit Protection
Cash Accumulation for Future Retirement Needs
Emergency Fund
Financially Support Loved Ones
Mortgage Protection
Pay Funeral Costs
Replace an Existing Policy
Cover Debts
Other
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16
Are you currently taking any prescription medications?
*
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YES
NO
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17
In the past 5 years have you been treated or prescribed medication for any of the following conditions?
*
This field is required.
Select all that apply
Anxiety / depression / bipolar
Cancer
Chronic pain
Diabetes
Heart or circulatory disorder
Respiratory disorder
Other medical condition
I have no medical conditions
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18
If you are looking to obtain a quote for a permanent type of life insurance (Indexed Universal Life - IUL, Whole Life, Variable Life), how much can you start contributing?
An estimate is fine
Contribution Amount
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19
What is the amount of coverage you have in mind?
*
This field is required.
Please Select
I don't know, help me decide
Less than $30,000
$30,000 - $49,000
$50,000 - $100,000
$100,000 - $249,000
$250,000 - $500,000
$500,000 - $1,000,000
$1,000,000 +
Please Select
Please Select
I don't know, help me decide
Less than $30,000
$30,000 - $49,000
$50,000 - $100,000
$100,000 - $249,000
$250,000 - $500,000
$500,000 - $1,000,000
$1,000,000 +
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20
Where do you reside?
*
This field is required.
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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21
What is your e-mail address?
*
This field is required.
The email address that you provide will ALWAYS be kept confidential, secure and will not be sold or redistributed.
Ex: life@comfortif.com
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22
What is your phone number?
*
This field is required.
The phone number that you provide will ALWAYS be kept confidential, secure and will not be sold or redistributed.
Area Code
Phone Number
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23
What is your preferred method of contact?
*
This field is required.
Phone Call
E-Mail
Text Message
Phone Call
E-Mail
Text Message
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24
What is the best time of day to reach you?
*
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2
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12
Hour
00
10
20
30
40
50
00
10
20
30
40
50
Minutes
AM
PM
PM
AM
PM
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25
What is your preferred language?
*
This field is required.
Please Select
English
Spanish
Please Select
Please Select
English
Spanish
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26
Please add anything you'd like our agents to be aware of
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27
DISCLAIMER: By submitting your information, you agree that a representative from the agency will contact you at the above-listed email or phone number. I understand that consent is not a condition of purchase and that this does not guarantee issuance of coverage.
*
This field is required.
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28
Please verify that you are human
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