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Personal Information
Name
*
First Name
Last Name
Do you have a preferred name?
Date of birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
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Please select a year
2013
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1920
Year
Cell phone number
-
Area Code
Phone Number
Home phone number
-
Area Code
Phone Number
Which is your preferred phone?
*
Cell Phone
Home Phone
Personal email
*
Work email
Which is your preferred email?
*
Personal Email
Work Email
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
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Connecticut
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District of Columbia
Florida
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Hawaii
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
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Wyoming
State
Zip Code
What is your preferred method of contact?
*
Phone
Email
What is your preferred method for a meeting?
*
In Person
Virtual Meeting (Skype, etc)
Phone Call
What is the reason you are looking for insurance now?
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Page 2 of 5
Employment Status
Are you
*
Employed
Retired
Business Owner/Self-Employed
Homemaker
Not currently employed, but looking
Would you be interested in a getting a quote for group health insurance for your employees?
Yes
No
Name of business
Number of employees?
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Page 3 of 5
Family Information
Are you
*
Married
Single
Divorced
Widowed
Will your spouse be included on the policy?
*
Yes
No
Not Applicable
Spouse's name
First Name
Last Name
Spouse's date of birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
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28
29
30
31
Day
Please select a year
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
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1925
1924
1923
1922
1921
1920
Year
Is your spouse
Employed
Retired
Business Owner
Homemaker
Not currently employed, but looking
Will there be any children on the policy?
*
Yes
No
1st child's name
1st child's birth date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
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29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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1931
1930
1929
1928
1927
1926
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1922
1921
1920
Year
2nd child's name
2nd child's birth date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
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12
13
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15
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30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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2003
2002
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1991
1990
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1982
1981
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1978
1977
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1972
1971
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1967
1966
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1964
1963
1962
1961
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1959
1958
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1956
1955
1954
1953
1952
1951
1950
1949
1948
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1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
3rd child's name
3rd child's birth date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
4th child's name
4th child's birth date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Do you plan on having additional children?
Yes
No
Maybe
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Page 4 of 5
Health Insurance
What is your desired effective date?
*
-
Month
-
Day
Year
Date
Do you currently have health insurance insurance?
*
Yes
No
How much is your current monthly premium?
What is your current deductible?
amount must you pay before insurance pays your bills
How often do you visit the doctor?
Is there a Doctor copay or co-insurance?
Yes
No
I don't know
How much is it?
amount you pay per visit to the doctor or hospital or per treatment
Does anyone applying use tobacco?
*
Yes, me
Yes, my spouse
Both of us
Neither one of us
Do you take any prescription medication?
*
Yes
No
I don't know
What prescription drugs are you taking?
What is a comfortable budget for you?
Which doctor(s) or hospital(s) would you like in-network?
Do you want or qualify for a subsidy with Marketplace/ACA/Exchange plans?
Yes
No
I don't know
What your tax household size?
What is your tax household annual income?
Life Insurance
Do you currently have any life insurance?
Yes
No
I don't know
Do you want a quote for life insurance?
Yes
No
I don't know
Policy Type
Please Select
Term
-10 years
-20 years
-30 years
Whole Life
Universal Life
I don't know
What is your desired death benefit?
amount your beneficiary or beneficiaries receive upon your death
Do you want to add a critical illness rider?
Yes
No
I don't know
Desired budget limit?
Do you feel you have adequate insurance protection to cover your family's needs if something were to happen to you?
Yes
No
Not sure
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Page 5 of 5
Bonus Questions
Are there any questions or concerns you have?
How was your experience filling out this form?
Who is your agent/broker?
*
Jay
Ani
Don't Know
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