Clone of Diligent Healthcare Solutions Insurance Inquiry

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Select the topics that you would like to discuss

Final ExpenseRecovery/ Short Term Care InsuranceI am not sure
Why are you looking for a Final Expense program (Check all that apply)?*

I want my end-of-life expenses covered to ease the financial burden on my familyTo pay for health emergency costs, such as cancer, stroke, long term illnessI'm looking to replace my current policy with something more affordableI currently have a policy but would like additional coverageOther
Note: If you currently have a policy, please have the policy nearby. If you can't find it, we can help you get another copy
How do you feel about getting life insurance(Check all that apply)?*

ConfidentGuilty/AshamedFrustratedOverwhelmedAnxiousClueless
Do you currently have a Life Insurance Policy?*

No, I do not have a policy in placeYes (Note: Please have the policy nearby if you have it. If you can't find it, we can help you get another copy)
Who will be the Beneficiary?*
The beneficiary is the primary person or entity who will receive the death benefit from a life insurance policy when the person passes away.
Beneficiary's Name *
Have you ever had life insurance that was declined, rated, canceled or postponed?

NoYesI'm not sure
Health Questions

This is to help the agent prequalify you for the Final Expense Program that will best meet your needs at the most affordable rate. All information that you share will be kept confidential. Please be as accurate as possible. Insurance Carriers will verify can verify accuracy by running you mib report. For more information about your MIB report, go to www.mib.com.
What is your gender?*

MaleFemale
What is your date of birth?*

MonthDayYear
This helps us recommend an insurance product that meets you where you are in life.
Height (ft)*
Weight (lbs)*
Skip the scale, provide us with you best estimate
What products have you used in the last 12 months?*

NoneChewing TobaccoMarijuanaVaping and e-cigarettesCigarettesCigars
At any time, have you been medically diagnosed, treated, or had surgery for any of the following*

NoneLung Disease, COPD, or EmphysemaCancerAsthmaDiabetes - Insulin DependentDiabetes - No InsulinHeart AttackCongestive Heart FailureStrokeKidney ProblemsCirrhosisHepatitisHIV/AIDSOther serious condition
Have you been hospitalized overnight within the past 2 years?*

NoYes (Agent may ask you the dates of each hospitalization)
At any time, have you been medically diagnosed, treated, or had surgery for any of the following

NoneCancerDiabetesHeart/Cardiac ProblemsLung or Respiratory ProblemsStrokeKidney or Liver ProblemsNeurodegenerative Disorders (Parkinson'sDisease, Lou Gehrig's Disease, Alzheimer's Disease, Dementia, multiplesclerosis, muscular dystrophy, cerebral palsy)SeizuresOther serious condition
Most insurance carriers will require you to have a checking or savings account from a local bank. However, some will accept a Pre-Paid Debit card such as Direct Express. Which one do you use? (Note: No payment is required until the policy has been issued and you've accepted it)*
(Note: No payment is required until the policy has been issued and you've accepted it)
Your Budget Requirement

The better we understand your financial situation, the better we can maximize your financial future. You don’t have to pay anything until the policy has been issued and you’ve accepted it.
If you can qualify you for a program today, what would be considered an affordable monthly rate (optional)?
No payment is due today.
Coverage/Death Benefit Amount (Optional)
The death benefit is the money your beneficiary receives from your life insurance company after you pass away. On average, final expense death benefits range anywhere from $5,000 to $50,000.
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Once submitted, you will be assigned to a local licensed professional who will contact you within 24 hours to assist you in understanding the available options tailored to your needs. You will receive your free Walmart Gift Card after receiving your quote.
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Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Best time to reach you (Check all that apply)?*

Between 11am-1pmBetween 1pm-3pmBetween 3pm-5pmBetween 5pm-7pmAnytimeWeekends Only
Zip Code*
This helps us find the right products available to you in your area.
I prefer to meet...*

Over the PhoneVirtually (We use Zoom)In-Person (Limited to certain areas)Doesn't Matter
Optional: This will be needed later to deliver your policy information.

Street Address

Street Address Line 2

CityState

Zip Code
Reconfirm Favorite Hobby*
Used for verification purposes
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By checking this box, I consent to receive SMS from Diligent Senior Living Solutions LLC dba Diligent Healthcare Solutions. You can opt out any time by texting STOP; For assistance, text HELP or visit our website at www.diligenthealthcaresolutions.com; Message & data rates may apply; You may receive 1 messages per day.Messaging frequency may vary. You agree our Terms of Use and that an authorized representative or licensed insurance agent may contact you via phone, text and/or email to answer your questions or to provide additional information about your insurance plan options. Our Privacy Policy describes information collection and use. Visit https://www.diligenthealthcaresolutions.com/privacy-policy for privacy policy and https://www.diligenthealthcaresolutions.com/sms-terms-conditions for Terms of Service.
Please verify that you are human*
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Note: If you currently have a policy, please have the policy nearby. If you can't find it, we can help you get another copy

Health Questions

Your Budget Requirement

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