Lead Submission - Advisors/Agents

Lead Submission - Advisors/Agents
Primary Contact Name

First NameLast Name
Preferred Name
Spouse Name

First NameLast Name
Preferred Name
Primary Contact Phone Number
Please enter a valid phone number.
Primary Contact Email
example@example.com
Referral Source
Existing client?

YesNo
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Which leads are being submitted?

TaxHealth InsuranceLife InsuranceHome & Automotive InsuranceMortgage FundingEstate PlanningFinancial
Tax
DOB

MonthDayYear
Date
Are they...

RetiredSelf EmployedWage Earner
What is their income?
What help do they need?

Tax PlanningTax PreperationTax Advice
What is their state of residence?
Other Notes & Information
Health Insurance
Products Inquired

Medicare AdvantageMedicare SupplementPrescription Drug Plan(PDP)LTC/STCACA(Obamacare)Other
Client Age
Case Notes & Information
Life Insurance
Life Insurance type

TermWholeUniversalOther
Estimated Coverage Needed ($)
Case Notes & Information (please specify purpose, term, etc.)
Home & Automotive Insurance
Primary Applicant Date of Birth

MonthDayYear
Date
Does the applicant rent or own?

RentOwn
Additional Properties (Street Address - Address, Zip Code, City, State)
Vehicles - Make, Model, Year
Case Notes & Information
Mortgage Funding
Borrower Date of Birth

MonthDayYear
Date
Co-Borrower Date of Birth

MonthDayYear
Date
Estimated Property Value ($)
Loan Type:

New Home PurchaseRefinanceReverse MortgageOther
Existing Loan Balance ($)
Existing Loan Term
Existing Loan APR
Case Notes & Information:
Estate Planning

Referred to Simplify Estate Planning
Included with Trust Estate Plans:
- Lifetime Amendments to the Trust
- Pour-over Will
- Healthcare Power of Attorney
- Durable Power of Attorney
- Transferring Two (2) Michigan Deeds
- Docubank (HCPOA & Emergency Contacts Card) Included for 5 years
- Out of State Deeds - USDeeds.com (Third Party) Fees vary based on State
Estate Plan: (Please do not disclose exact pricing)

Current Estate Plan Review (Starts at $350, please provide current documents)Trust AmendmentDeedIndividual - Will Estate Plan ($1,500 = 20% Discount)Married Joint - Trust Estate Plan ($2,500 = 30% Discount)Married Separate - Trusts Estate Plan ($3,200= 30% Discount)Married - Will Estate Plan ($1,900 = 20% Discount)Individual - Trust Estate Plan ($2,000 = 30% Discount)
Discount: (If applicable)

Friends and Family Discount (additional 10%)
Case Notes & Information
Financial
Received statements/documents?

YesNo
Investable Assets Amount
Case Notes & Information
Please upload any additional files here

Cancelof
Should be Empty:

Lead Submission - Advisors/Agents

Tax

Health Insurance

Life Insurance

Home & Automotive Insurance

Mortgage Funding

Estate Planning

Financial