Clone of Diligent Healthcare Solutions Insurance Inquiry

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Select the topics that you would like to discuss
Why are you looking for a Final Expense program (Check all that apply)?

Other
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)?
Do you currently have a Life Insurance Policy?
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?
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?
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?
At any time, have you been medically diagnosed, treated, or had surgery for any of the following
Have you been hospitalized overnight within the past 2 years?
At any time, have you been medically diagnosed, treated, or had surgery for any of the following
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)?
Zip Code
This helps us find the right products available to you in your area.
I prefer to meet...
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
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.
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Get a free quote, and receive a Walmart Gift Card!

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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