Pre-Screening Insurance Quote Form

Pre-Screening Insurance Quote Form

Congratulations on taking the first step to securing you and your family's future! Once we receive this form, we will send you out a short video to educate you more on the different products that we have to offer along with a group text message. Once you have watched the video, Brittany Taylor will reach out to you to set up a brief zoom call to complete your quote.

This form must be completed for each person 18+ receiving a quote.
Personal Info
Full Name
Email
example@example.com
Full Address including City State & Zip
Phone Number
Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
Martial Status?

Other
Employment and Income Information
Do you have a high-risk job (e.g., military, law enforcement, occupational travel, etc.)?
Occupation?
Employer?
Employment Status
Annual Income?
Health and Lifestyle Information
Height
Weight
Tobacco Smoker or Non Smoker? (If you smoke marijuana and/or vape, please indicate below. This will NOT disqualify you from receiving coverage.) If yes, list frequency in other option.

Other
Alcohol use?
Do you have ANY medical diagnosis? If so list every diagnosis below
Do you have ANY mental health diagnosis? If so list every diagnosis below
Have you been prescribed ANY medications within the past ten years? If so, list EVERY medication below. Include all medications whether you are taking them or not.
Have you been hospitalized in the past 12 months If so please list the dates and the causes
Who is your Primary Care Physician?
Do you receive ANY disability benefits?
Coverage Information
Do you currently have any private life insurance policies outside of your job? If so, is it a whole life or Term policy?
Which Life Plan would you like quoted? (Select all that apply.)
What is your monthly budget for your policy
How much life insurance coverage would you like for us to quote
Do you currently have a retirement account?
Are there any additional family members you would like to cover If so please provide their names and date of birth
Who is your beneficiary? List them below.
Background Information
Have you had any DUI's, DWI's, reckless driving or moving violations in the past 10 years?
Have you been convicted of a felony, currently awaiting trial for a felony, or any incarceration in the past 5 years?
Financial Goals
What are your goals with this policy?

Other
Are you interested in being an agent?
Anything else we should know?
Schedule a call
Appointment
I understand that I will receive an email and text with the zoom link.
Should be Empty:

Personal Info

Employment and Income Information

Health and Lifestyle Information

Coverage Information

Background Information

Financial Goals

Schedule a call