Blue Zone Insurance Intake Form

Blue Zone Living Benefits Insurance - Discovery & Protection Strategy Survey
Section 1 - CLIENT INFORMATION
Full Name
Date of Birth

MonthDayYear
Date
- Marital Status (Single, Married, Domestic Partner, Widowed, Divorced):
- Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Occupation & Employer
Are you a business owner?
If yes, which industry?
If yes, employee count?
Section 2 - FINANCIAL SNAPSHOT
Annual income
What assets/policies do you currently own? – Multiple Choice

Other
If you couldn’t work, how many years would savings last?
Do you have financial dependents? – Multiple Choice
How confident are you in your retirement plan?
Section 3 - HEALTH & ELIGIBILITY
Any health conditions or medications?
If yes, please list medications.
History of cancer, heart issues, stroke?
Tobacco/nicotine use?
Do you currently have health insurance?
If yes, please explain.
Section 4 - PROTECTION PRIORITIES
What are your top 3 concerns? – Checkboxes, max 3 selections
Financial impact if something happened today – Single Choice
Interest in tax-diverting strategy?
Section 5 - STRATEGY DISCOVERY
What prompted you to explore coverage now? – Checkboxes
Top 3 goals in next 3–5 years
Open to a complimentary policy review?
Would you like to learn about wealth-building tools?
Section 6 - FINAL THOUGHTS + SCHEDULING
If we could help with one thing this year…
Anything else you'd like us to know?
When’s best to reach out? – Multiple Choice
Preferred day of week – Dropdown (Monday to Sunday)
Should be Empty:

Section 1 - CLIENT INFORMATION

Section 2 - FINANCIAL SNAPSHOT

Section 3 - HEALTH & ELIGIBILITY

Section 4 - PROTECTION PRIORITIES

Section 5 - STRATEGY DISCOVERY

Section 6 - FINAL THOUGHTS + SCHEDULING