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.
- Name*
  
  First NameLast Name
- E-Mail*
  Email
- Phone Number*
  Format: (000) 000-0000.
- Preferred Contact Method
  
  PhoneEmailText Message
- (Multiple Choice - allow multiple selections)
  
  Personal InsuranceBusiness Insurance
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- Do you currently use tobacco products?
  
  YesNo
- Do you currently have life or health insurance?
  
  YesNo
- (If Yes, show short text to enter carrier name)
- What type of personal coverage do you need?
  
  Life InsuranceHealth InsuranceAuto InsuranceHomeowners or RentersDisability InsuranceUmbrella PolicyLong-Term CareIndexed Universal Life (IUL)Medicare
- 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 ServiceOffer Direct DepositOffer Health InsuranceOffer a 401k PlanOther
- Do you operate from a physical location?
  
  YesNo
- Do you have company-owned vehicles?
  
  YesNo
- Commercial Insurance
  optional
- Payroll Provider
  optional
- Health Insurance
  optional
- Business Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- What type of business insurance do you need?*
  
  General LiabilityWorkers’ CompensationBusiness AutoCommercial PropertyKey Person or Buy-Sell InsuranceCyber LiabilityProfessional Liability / E&OGroup Health / BenefitsBusiness Interruption
- 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
- How did you hear about Simone Whiteside Insurance Producer?*
  
  WebsiteSocial MediaReferralEvent / WorkshopOther
- Comments or Questions? (Long Text)
- ☐ I authorize Simone Whiteside to obtain insurance quotes on my behalf and contact me regarding coverage options.*
  
  YesNo
- Signature*
- Date Signed
  
  MonthDayYear
  Date
- Should be Empty:

Insurance Assessment Form