Lead Submission - Advisors/Agents
Primary Contact Name
First Name
Last Name
Preferred Name
Spouse Name
First Name
Last Name
Preferred Name
Primary Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact Email
example@example.com
Referral Source
Please Select
shanna@clearstrategy.team
msanlor@clearstrategy.team
tracy@clearstrategy.team
cieara@clearstrategy.team
mark@clearstrategy.team
ryan@clearstrategy.team
cathy@clearstrategy.team
todd@clearstrategy.team
paul@clearstrategy.team
eric@clearstrategy.team
beth@clearstrategy.team
tj@clearstrategy.team
nick@clearstrategy.team
matt@clearstrategy.team
devin@clearstrategy.team
dom@clearstrategy.team
brianna@clearstrategy.team
angelo@clearstrategy.team
carrie@clearstrategy.team
hunter@clearstrategy.team
klitton@clearstrategy.team
Existing client?
Yes
No
Address
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Which leads are being submitted?
Tax
Health Insurance
Group Health Insurance
Life Insurance
Home & Automotive Insurance
Mortgage Funding
Estate Planning
Financial
Financial Planning
Rep Information
Servicing Representative:
Please Select
brianna@clearstrategy.team
devin@clearstrategy.team
dom@clearstrategy.team
eric@clearstrategy.team
nick@clearstrategy.team
tj@clearstrategy.team
todd@clearstrategy.team
Include Servicing Rep in presentation meeting?
Yes
No
Case Information:
Client Name:
*
First Name
Middle Name
Last Name
Spouse Name:
First Name
Middle Name
Last Name
Client Status:
Please Select
Existing Client
Prospect
Plan Completion - Date Requested
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Quote Given? Respond if "Yes". Skip if "No".
Brief summary of client(s) situation:
*
Please include any key life changes, events, or financial obligations.
Please attach any related files for this case:
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Tax
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are they...
Retired
Self Employed
Wage Earner
What is their income?
What help do they need?
Tax Planning
Tax Preperation
Tax Advice
What is their state of residence?
Other Notes & Information
Health Insurance
Products Inquired
Medicare Advantage
Medicare Supplement
Prescription Drug Plan(PDP)
LTC/STC
ACA(Obamacare)
Other
Client Age
Case Notes & Information
Life Insurance
Life Insurance type
Term
Whole
Universal
Other
Estimated Coverage Needed ($)
Case Notes & Information (please specify purpose, term, etc.)
Home & Automotive Insurance
Primary Applicant Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does the applicant rent or own?
Rent
Own
Additional Properties (Street Address - Address, Zip Code, City, State)
Vehicles - Make, Model, Year
Case Notes & Information
Mortgage Funding
Borrower Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Co-Borrower Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Estimated Property Value ($)
Loan Type:
New Home Purchase
Refinance
Reverse Mortgage
Other
Existing Loan Balance ($)
Existing Loan Term
Please Select
10
15
20
30
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 Amendment
Deed
Individual - 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?
Yes
No
Investable Assets Amount
Please Select
$0-$100k
$100k-$250k
$250k-$500k
$500k-$1mil
$1mil+
Case Notes & Information
Please upload any additional files here
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Submit
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