Insurance is based on your AGE, your HEALTH, and your HABITS!
See if You Qualify Now... Are we a FIT to work together?
As The Insurance Chick, I value your time and mine. This quick form helps me understand your unique needs and see if you qualify for the right life insurance policy. By filling it out, I can make sure we’re a good fit before moving forward, ensuring we both save time and focus on what really matters—finding the best coverage for you.
Name
*
First Name
Last Name
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Budget/Income: Ability to afford life insurance coverage.
*
Yes, I can afford the cost of insurance
No, I don't have funds to pay for coverage
Date of Birth
*
-
Month
-
Day
Year
Date
Health: Have you smoked in the past 12 months? (vape, nicotine, weed)
*
Please Select
YES
NO
Any major health issues?
*
HBP
Diabetes
Cancer
PCOS
Heart Attack
Stroke
HIV
COPD
Sleep Apnea
None
Dialysis
Other
Diagnosis date or last treatment date:
*
NA if you selected none above
Any previous DUIs, reckless driving, suspended license, felony charges or probation in the past 10 years?
*
Please Select
Yes
No
Health: Height
*
Health: Weight
*
What type of insurance do you have in place already?
Term policy
Permanent policy
On the job policy
I don't have any coverage at all
What type of insurance are you interested in?
*
Term
Whole
IUL
Annuity
Not sure, guide me
Preferred Coverage Amount if you qualify
*
up to $50,000
up to $500,000
Calculate my insurance needs for me
Who will be your beneficiary (NAME and CELL number)?
*
Who do you trust me to deliver your death benefits to from your life insurance policy? List their name and number (over 18)
Do you have anything that acts like life insurance?
*
Old 401k
Old Pension
Excess cash laying around not earning much interest
None
What would life look like if you DON'T get this coverage put in place for your family? Be honest please
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit (I will call you, please answer)
Should be Empty: