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.Format: (000) 000-0000.
Primary Contact Email
example@example.com
Referral Source
Existing client?
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Which leads are being submitted?
Tax
DOB

MonthDayYear
Date
Are they...
What is their income?
What help do they need?
What is their state of residence?
Other Notes & Information
Health Insurance
Products Inquired

Other
Client Age
Case Notes & Information
Life Insurance
Life Insurance type
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?
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 ($)
Loan Type:
Existing Loan Balance ($)
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)
Discount: (If applicable)
Case Notes & Information
Financial
Received statements/documents?
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