Life & Legacy Coverage Request

1

What’s your full name?* This field is required.

Prefix

First Name

Last Name

2

What’s your date of birth?

Date

3

Gender* This field is required.

Male

Female

4

Age* This field is required.

5

What’s your 5-digit ZIP code?

6

Which email address should I send your quote details to?

example@example.com

7

Phone Number (Mobile)

8

What’s the main reason you’re considering coverage?

Final Expenses / Burial

Life Insurance

Income Protection

Family Support / Legacy

Other

9

How much coverage are you looking for?

$10,000–$25,000

$25,000–$50,000

$50,000+

Not sure yet 🌿

10

Do you currently use or have used any tobacco or nicotine products in the past 12 months?

YESNO

11

Have you been diagnosed with or treated for any of the following in the past 2 years?

Diabetes

Heart Condition

Cancer

COPD

None of these

12

Who would you like to name as your primary beneficiary?

13

When’s the best time for Candace to call or text?

Morning (9–12)

Afternoon (12–4)

Evening (4–7)

Anytime works 🌿

14

By submitting, you agree to be contacted by a licensed agent (Candace Larry) about life insurance options. This is a free, no-obligation consultation. Covered by Candace is an independent agency, not affiliated with any government program.

I understand and agree.