3 Min. Customer Survey v3

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Hello, my name is Sean and I'll be the broker assisting with your insurance needs today.

Please complete the quick 3-Minute Customer Survey and I'll shop insurance rates and plans for you and supply a quote within 24 hours.

We appreciate the opportunity to assist with your insurance needs.

Sean Blake

Independent Agent/Licensed Broker

314-756-0303

*For Group Rates please Contact us by Telephone (314-756-0303) or Email (sean@mybrokerbenefits.com).
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Name & Family* This field is required.
FIRST NAME
LAST NAME
Please Select
Please Select
Single
Married
MARITAL STATUS
# OF CHILDREN UNDER AGE 26
3
Contact Information* This field is required.
TELEPHONE #
EMAIL
STATE
CITY & ZIP CODE
4
Do you agree to be contacted by Sean Blake by telephone, email and text message, regarding your request for a health/life insurance quotation? * This field is required.We will send your quote by email & text message.
YESNO
5
What type of plan are you interested in? How can we best help you today?
6
What is Your Job/Occupation?* This field is required.
Self-Employed
Employed PART TIME
Employed FULL TIME
Semi-Retired
Retired
Student or Military
Medical Disability
Other
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Select the types of Health/Life Insurance you Currently have or own?* This field is required.Select All That Apply
Major Medical: Group/Employer Provided
Major Medical: Private Plan
Major Medical: ACA
Medicare
Term Life Insurance
Whole Life Insurance
Health Supplement
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Is There Anything You LIKE or MUST KEEP About Your Current Insurance?* This field is required.Example: Network, Coverages of interest etc.
.
9
What do You DISLIKE About Your Current Insurance?* This field is required.Example: Premiums too high, or need a new plan etc.
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How much do you pay each month for your insurance?* This field is required.Example: who pays (employer vs self), monthly premiums etc
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Please Tell Us Age & Health of Those Seeking CoverageList Children up to Age 26
Age
Major illness?
Tobacco User?
Primary
Row 0, Column 0
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 0, Column 1
Yes
No
Row 0, Column 2
Spouse
Row 1, Column 0
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 1, Column 1
Yes
No
Row 1, Column 2
Child 1
Row 2, Column 0
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 2, Column 1
Yes
No
Row 2, Column 2
Child 2
Row 3, Column 0
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 3, Column 1
Yes
No
Row 3, Column 2
Child 3
Row 4, Column 0
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 4, Column 1
Yes
No
Row 4, Column 2
Child 4
Row 5, Column 0
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 5, Column 1
Yes
No
Row 5, Column 2
Primary
Spouse
Child 1
Child 2
Child 3
Child 4
Age
Row 0, Column 0
Major illness?
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 0, Column 1
Tobacco User?
Yes
No
Row 0, Column 2
Age
Row 1, Column 0
Major illness?
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 1, Column 1
Tobacco User?
Yes
No
Row 1, Column 2
Age
Row 2, Column 0
Major illness?
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 2, Column 1
Tobacco User?
Yes
No
Row 2, Column 2
Age
Row 3, Column 0
Major illness?
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 3, Column 1
Tobacco User?
Yes
No
Row 3, Column 2
Age
Row 4, Column 0
Major illness?
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 4, Column 1
Tobacco User?
Yes
No
Row 4, Column 2
Age
Row 5, Column 0
Major illness?
No
Yes (last 3 yrs)
Yes (last 3-10 yrs)
Yes (last 20+ yrs)
Row 5, Column 1
Tobacco User?
Yes
No
Row 5, Column 2
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What's the best time of day to reach you by telephone (Mon thru Fri)?
Mornings: 8-11 AM
Mid-day: 11 AM - 1 PM
Afternoons: 1-4 PM
Evenings: 5-8 PM
By Appointment
Anytime
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Congratulations, you're all done.

We'll follow up with your shortly.

Have a great day!

Sean B.
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