Life Insurance Quote Form

Life Insurance Planning Quote Form

THIS IS NOT AN APPLICATION FOR INSURANCE.
Life Insurance Broker Engagement Form

The licensed broker information can be verified on the Georgia Insurance Commissioners website by using this link at https://www.sircon.com/ComplianceExpress/Inquiry/consumerInquiry.do?nonSscrb=Y.
I give my permission to SHACKISHA CLARK to serve as the life insurance agent or broker for myself and my entire household if applicable, for purposes of quoting or enrollment in life insurance policy to only the designated carriers or insurers. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:
1. Providing quotes and engaging in life insurance & financial planning consultation.
2. Completing an application for eligibility and enrollment in a life insurance plan when given consent to do so.
3. Providing ongoing account maintenance and enrollment assistance, as necessary; or
4. Responding to inquiries from the life insurance carrier to the insured for maintenance requests.

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

I confirm that the information I provide for entry on my enrollment application once given consent will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting the agent or insurance carrier chosen. Protecting your personal information is important.

Your personal information is not sold and will only be disclosed to the life insurance carriers that can provide the best quotes to you. Your information will only be used to provide insurance quotes to see what the best and most affordable premiums are available to you & what you may qualify for. To help you obtain competitive life insurance quotes, please provide information on your medical history, doctors, and other factors that may impact underwriting. This preliminary inquiry is not an actual insurance application and does not guarantee any coverage will be offered. This information is held confidential and released only to the life insurance companies an appointment is contracted with the broker.

Name of Primary Writing Agent: SHACKISHA CLARK

National Producer Number: 19092685
GA Resident Agent License Number is 3196512
Phone Number: 678-994-4069

Email Address: insurance@lifetimetaxprofessionals.com

Rows	Fill In Every Row
Primary Insured First & Last Name
Primary Insured Date of Birth
Phone Number
Email
Full Home Address
Marital Status (Married, Divorced, Single)
Are you a tobacco user?
Biological Gender? (Male or Female)
What is your height in feet and inches?
What is your current weight?
Occupation
When was your last doctor exam?
In the past 5 years have you filed for bankruptcy?
Ever convicted of a DUI or DWI? If so, WHAT DATE?
Ever convicted of a felony? If so, WHAT DATE & Explain?
Your Estimated Monthly Income (Not including spouse)
Please list all prescription medications you are currently taking that may impact your life insurance application.
List any major surgeries you have had and the dates performed that may impact your life insurance application.

Rows	Fill In Every Row
Spouse First & Last Name
Spouse Date of Birth
Phone Number
Email
Full Home Address
Are you a tobacco user?
Biological Gender? (Male or Female)
What is your height in feet and inches?
What is your current weight?
Occupation
When was your last doctor exam?
In the past 5 years have you filed for bankruptcy?
Ever convicted of a DUI or DWI? If so, WHAT DATE?
Ever convicted of a felony? If so, WHAT DATE & Explain?
Your Estimated Monthly Income (Not including spouse)
List all prescription medications you are currently taking that may impact your life insurance application.
List any major surgeries you have had and the dates performed that may impact your life insurance application.

Dependents

Information Regarding Your Child(ren) Under the Age of 18

Please provide the information below if you would like to receive an additional quote for a potential individual insurance policy for your child(ren).

Rows	Full Name	Date of Birth	Gender at Birth	Height (Ft / In)	Weight (lbs.)	Date of Last Doctor Visit	Doctor or Facilty Name	Prescriptions?	List Known Medical Condition and or surgeries
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AUTHORIZATION TO PROVIDE QUOTES & CONSULTATION

I understand that if I choose not to sign this authorization, the Representative may be unable to provide complete information about the insurance coverage and costs available to me. I also acknowledge that the insurers listed on this form, or any I formally apply to, may require me to sign a separate authorization specific to their organization before processing my application or offering coverage. I understand that refusing to sign this authorization will not affect my ability to receive treatment, payment for services, or eligibility for health care benefits. However, I recognize that if a healthcare service, such as a physical exam, is requested solely to generate protected health information for disclosure to a third party, the healthcare provider may decline to provide the service if I do not sign this authorization.
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Life Insurance Planning Quote Form

Life Insurance Broker Engagement Form

Proposed Primary Insured General Information

Dependents

Your Why

AUTHORIZATION TO PROVIDE QUOTES & CONSULTATION