Client Consult Request Form

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Which State do You Live in?* This field is required.

5

What is your PRIMARY concern?* This field is required.

My family needs money to maintain their lives if I die early

I don't want to leave a financial burden when I pass

I want to set up an Infinite Banking Concept policy to protect investments from interest and taxes.

6

What's Your Date of Birth?

7

Have You Been Diagnosed or Treated for Any of The Following?* This field is required.

Cancer

Heart Attack/Heart Failure

Organ Failure/Dialysis

Diabetes

Autoimmune Disease

Severe Depression/Anxiety

Substance Abuse

None of the Above

8

Describe Your Documented Smoking History* This field is required.

Never Smoker

Prior Smoker (more than 1 year ago)

Prior Smoker (more than 3 years ago)

Occasional Pipe/Cigar Smoker

Regular Vape Use/Current Smoker

I have smoking cessation prescriptions on my record

9

Do You Have a Felony on Your Record in the last Decade?* This field is required.

YESNO

10

Has Your Drivers' License Been Suspended in the Last Decade?* This field is required.

YESNO

11

Describe Your Financial SituationSelect all that apply

I have a 401k I'm no longer contributing to.

I have at least $100k in cash I'm looking to invest.

I have at least $500/mo I could invest if the numbers looked good.

12

Tell Us In Your Own Words What You're Looking For* This field is required.

13

ONE specially trained agent will attempt to contact you, is that OK?* This field is required.We promise not to spam you. We will not sell or give anyone else your information.

YESNO