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Let's Find the Best Plan For You
Answer a few short questions to help us understand your needs and guide you toward the right protection. This pre-assessment is for guidance only - confidential and obligation-free.
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1
Please verify that you are human
*
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2
Name
*
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First Name
Last Name
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3
Email
*
This field is required.
example@example.com
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4
Phone Number
*
This field is required.
Please enter a valid phone number.
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5
Province
*
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Please Select
Alberta
British Columbia
Please Select
Please Select
Alberta
British Columbia
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6
Gender
*
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Please Select
Male
Female
Other
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Please Select
Male
Female
Other
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7
Are you a smoker?
*
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YES
NO
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8
Age
*
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Below 18 years old
18 - 30 years old
31 - 40 years old
41 - 50 years old
51 - 60 years old
61 - 70 years old
71 - 80 years old
Over 80 years old
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9
What type of coverage or product are you most interested in?
*
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Select all that apply
Life Insurance
Critical Illness
Disability Insurance
Health and Dental Insurance
Travel Insurance
Group Insurance
Investment
Others
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10
When do you plan to put coverage in place?
*
This field is required.
Immediately (within 30 days)
Within 1-3 months
Just researching
No Timeline
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11
What monthly budget have you set aside for this coverage?
Over $250
$100 - $249
Under $100
Unsure
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12
Do you currently have insurance coverage?
No, I need new coverage
Yes, but I want a review/upgrade
Yes, and I'm satisfied
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13
What is your top priority right now?
Protecting Family Income
Saving for Retirement
Exploring Options
Just Learning
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14
Terms and Conditions
*
This field is required.
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15
Province (Zoho)
Please Select
Please Select
Please Select
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16
Lead Status
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17
Lead Status (Zoho)
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18
Province (Zoho)
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