Insurance Assessment Form
Insurance with Heart. Protection with Purpose.— Simone Whiteside
SECTION 1: Contact Information
Name
*
First Name
Last Name
E-Mail
*
Email
Phone Number
*
Preferred Contact Method
Phone
Email
Text Message
SECTION 2: What Type of Insurance Are You Looking For?
(Multiple Choice - allow multiple selections)
Personal Insurance
Business Insurance
SECTION 3: Personal Insurance Information
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Prefer not to say
Do you currently use tobacco products?
Yes
No
Do you currently have life or health insurance?
Yes
No
(If Yes, show short text to enter carrier name)
What type of personal coverage do you need?
Life Insurance
Health Insurance
Auto Insurance
Homeowners or Renters
Disability Insurance
Umbrella Policy
Long-Term Care
Indexed Universal Life (IUL)
SECTION 4: Business Insurance Information ( only if “Business Insurance” is selected)
Company Name
*
Company Name
Estimated Yearly Payroll
Business Description
*
Business Description
Years in Operation
Annual Gross Revenue
How many employees do you have?
What Does Your Company Use
Use a Payroll Service
Offer Direct Deposit
Offer Health Insurance
Offer a 401k Plan
Other
Do you operate from a physical location?
Yes
No
Do you have company-owned vehicles?
Yes
No
Commercial Insurance
optional
Payroll Provider
optional
Health Insurance
optional
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of business insurance do you need?
*
General Liability
Workers’ Compensation
Business Auto
Commercial Property
Key Person or Buy-Sell Insurance
Cyber Liability
Professional Liability / E&O
Group Health / Benefits
Business Interruption
SECTION 5: Additional Preferences
What is your monthly insurance budget?
Please Select
Under $50
$50-100
$100-200
$200+
Are you interested in policies that..
*
Build cash value
Offer living benefits
Provide flexible payment options
Include long-term care or chronic illness protection
When do you need coverage to start?
-
Month
-
Day
Year
Date
SECTION 6: Final Steps
How did you hear about Simone Whiteside Insurance Producer?
*
Website
Social Media
Referral
Event / Workshop
Other
Comments or Questions? (Long Text)
Consent & Signature
☐ I authorize Simone Whiteside to obtain insurance quotes on my behalf and contact me regarding coverage options.
*
Yes
No
Signature
*
Date Signed
-
Month
-
Day
Year
Date
Submit Form
Submit Form
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