Insurance Quote Assessment

Insurance Assessment Form

Insurance with Heart. Protection with Purpose.— Simone Whiteside
“Submitting this form does not guarantee coverage. Information is used solely for quoting purposes and will not be shared without consent.”

Disclaimer: Licensed Insurance Producer in South Carolina (NPN: 21313998). Appointed with BlueCross BlueShield of South Carolina and other carriers. Plan availability depends on service area and carrier approval. Enrollment in Medicare Advantage plans depends on contract renewal with Medicare. Not connected with or endorsed by the U.S. Government or the federal Medicare program. This email may contain insurance marketing.

SECTION 2: What Type of Insurance Are You Looking For?
(Multiple Choice - allow multiple selections)

Personal InsuranceBusiness Insurance

SECTION 5: Additional Preferences
What is your monthly insurance budget?
Are you interested in policies that..*

Build cash valueOffer living benefitsProvide flexible payment optionsInclude long-term care or chronic illness protection
When do you need coverage to start?

MonthDayYear
Date

SECTION 6: Final Steps
How did you hear about Simone Whiteside Insurance Producer?*

WebsiteSocial MediaReferralEvent / WorkshopOther
Comments or Questions? (Long Text)

Consent & Signature
☐ I authorize Simone Whiteside to obtain insurance quotes on my behalf and contact me regarding coverage options.*

YesNo
Signature*

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Date Signed

MonthDayYear
Date
Should be Empty:

Insurance Assessment Form