Health Care And Protection Service Intake Form

Health Care & Protection Service Intake Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Discovery Call

MonthDayYear
Date
Best Time to call you

Hour Minutes

AM/PM Option
Preferred Contact Method*
Age Range*
Marital Status*

SingleMarriedPartneredDivorcedWidowed
Number of Dependents*
Current Coverage Status
Do you currently have health insurance?*

YESNO
If Yes, what type?*

Employer CoverageMarketplace/ObamacareMedicaidMedicarePrivate InsuranceOther
Do you currently have life insurance?*

YESNO
Do you currently have accidental death coverage?*

YESNO
Do you currently have a dental or vision plan?*

DentalVisionBothNone
Healthcare Questions (Legal & Compliant)
How would you describe your overall health?*

ExcellentGoodFairPoor
Do you currently have a primary care physician?*

YESNO
When was your last wellness or check-up visit?*

Within the last year1–3 yearsOver 3 years agoNot sure
Do you take any regular prescriptions?*

YESNO
If yes, approximately how many per month?*
Do you smoke or use tobacco?*

YESNO
Do you drink alcohol?*

RarelySociallyFrequently
Do you exercise at least 2–3 times per week?*

YESNO
Do you see any specialists (OB-GYN, chiropractor, cardiology, mental health, etc.)?*

YESNO
If yes, approx. how many visits per year?*
Protection & Financial Needs
Which of the following services are you MOST interested in?*

Affordable Life InsuranceAccidental Death CoverageDental / Vision PlansTax-Free Retirement GrowthFinal Expense / Burial ProtectionIncome ProtectionBuilding Family WealthUnderstanding Coverage Options
What is your #1 priority right now?*

Lowest Monthly CostBest Overall BenefitsFamily/Dependent ProtectionStrong Prescription CoverageLegacy Building / WealthCash Value Life Insurance
What is your preferred monthly budget?*

Under $50$50–$150$150–$300$300+
Lifestyle & Household
Do you own or rent your home?*

OwnRentOther
Do you support anyone financially other than dependents?*

YESNO
Important Links

Popl Digital Business Card

Popl Digital Business Card

Curtis Safe Money Solutions

https://curtissafemoneysolutions.com/

Accidental Death Product Guide (PDF)

https://a7d9021b860b18c4222a-d761a6fa6590560fc9f9e4d318d2556e.ssl.cf1.rackcdn.com/MoO-Accidental-Death-Product-Guide-6776b2c06ea50.pdf
Signature*

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Health Care & Protection Service Intake Form

Current Coverage Status

Healthcare Questions (Legal & Compliant)

Protection & Financial Needs

Lifestyle & Household