CONFIDENTIAL CLIENT INTAKE FORM Insurance is a tool that helps families, businesses, and churches prepare for favorable outcomes. Are you prepared?
We also offer final expense policies. Please complete this quick form to see if you qualify for our no wait, no exam policy and to receive a free quote. These policies are guaranteed issue, which means if you have pre-existing conditions, you won't have to wait the normal 2-4 year wait (in certain instances, not all) period before the policy pays out at 100%.
What type of plan are you looking to set up?
Life Insurance for myself- (no meds)
Life Insurance for myself- (Take Meds)
Life Insurance for Myself and another (Take Meds)
Life Insurance for Myself and another (no Meds)
Retirement Plan Services and/or transfer of accounts
Life insurance for someone else
Life Insurance or Retirement for my employees
Name
First Name
Last Name
Height and Weight
Be as accurate as possible
Date of Birth
Enter the Month, Date, and the Year
Are you a tobacco Smoker?
Answer yes or no
How many children under 19 who will be on this policy?
Answer yes/no. We will gather information on the child/ren at time of doing the policy when you move forward. Put n/a if this doesn't apply to you.
List your Medications
List all of your medications as they are written on your prescription bottle. Put n/a if this doesn't apply to you.
Do you have an existing retirement plan or are seeking to secure one?
We offer plans that ensure that you pay off your mortgage in the event of your death and also offer secure transfers from old accounts to ensure that your retirement will not run out. We have free living wills available for your planning needs.
About how much are you looking to rollover, deposit, or transfer into your retirement account?
Provide an amount that you plan to deposit, or advise in one lumpsum or if this will be monthly installments. Put n/a if this doesn't apply to you.
How much can you afford to pay monthly?
Give a range of how much you are able to pay towards securing your policy monthly. Put n/a if don't apply to you.
The best way to contact you to give you the free quote.
Provide your phone number or email address- put the email in this format: example@mail.com
What state do you live in?
Enter your State not the city. example: Tennessee or Wisconsin, etc.
Submit
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