New Client Intake

1

Let's get to know a little about you.Please provide your name below.

First Name

Last Name

2

Are you a Maine resident?This is to make sure we can work with you.

YESNO

3

Do you currently have life insurance (excluding employer plans)?It's important we understand the whole picture.

YESNO

4

AgePlease provide your current age.

5

Let us know if there are any immediate needs.

Mortgage Life Insurance

Term Life Insurance

Whole Life Insurance

Annuity

Help me decide

6

Let us know how we can help bestWe'll meet you at any stage of your planning.

7

Is there a specific face amount of insurance you are looking for?Don't worry, feel free to put "0" if you aren't sure.

8

Let's get to know a little about your health. Have you ever been diagnosed with or treated for the following? Please select those that apply.Don't worry, selecting one does not automatically disqualify you from plans.

Diabetes

Cancer

Heart attack

Stroke

Chronic Obstructive Pulmonary Disease (COPD)

HIV/AIDS

Seizures

None of the above

9

Let us know if we missed one. Are there any other health conditions we should be aware of?This ensures a reliable quote for insurance.

10

Within the last 12 months, have you used tobacco, in any form, or another nicotine product?This ensures a reliable quote for insurance.

YESNO

11

EmailThis allows us to send you options.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

12

Phone NumberThis helps us get in touch.

Please enter a valid phone number.