• Client Intake Form

    Tell me a little about yourself so I can see what you qualify for.

  • ⭐ What This Form Helps You Qualify For
    This short form helps me understand your situation so I can match you with the strongest options available. Depending on your answers, you may qualify for one or more of the following:

    💼 Business Funding (Self‑Employed / Business Owners)
    Fast working capital, micro‑funding, equipment financing, and lines of credit based on your revenue.

    🏢 Business Tax Credits (Business Owners with 1+ W2 Employees)
    Specialized tax incentives for companies with employees or physical locations.

    🧘‍♂️ FICA Savings & Employee Wellness Programs (Business Owners with 5+ W‑2 Employees)

    Payroll tax savings and enhanced employee wellness benefits for qualifying employers.

    💳 Zero‑Fee Payment Processing (Self‑Employed / Business Owners)
    Modern payment solutions that eliminate processing fees and improve cash flow.

    🏠 Mortgages for the Self‑Employed (Self‑Employed / Business Owners)
    Flexible mortgage options designed for entrepreneurs, 1099 earners, and business owners who don’t fit traditional lending guidelines.

     🏥 HealthShare Healthcare Plans (Self‑Employed / 1099 / W‑2 Employees)
    High‑quality healthcare with nationwide PPO access, low monthly costs, $0 telemedicine, discounted prescriptions, mental health support, and optional group plans for employers.

    🛡️ Life Insurance & Annuities (Families / Self‑Employed / Business Owners)
    Protection, long‑term planning, and financial security options for individuals, families, and business owners.

     
    Just answer the questions honestly - I’ll review everything personally and let you know exactly what you qualify for.

  • Format: (000) 000-0000.
  • Preferred Method of Contact*
  • Do you own a business or are you self‑employed?*

  • Business Information

  • Time in Business

  • Employee Structure (EHP + GMG)

  • Do you have any W‑2 employees?*
  • Do they work 32+ hours per week?
  • Are they permanent year‑round?
  • Do you currently have health insurance benefits in place for your employees?

  • Revenue & Operations (Funding)

  • Average monthly revenue*
  • How do you accept payments? (Check all that apply)

  • Tax Credits & Incentives (GMG)

  • Do you have physical business locations?*
  • What made you interested in exploring life insurance or annuities today?*
  • Do you currently have life insurance?*
  • What type of life insurance do you currently have?
  • Who are you looking to protect?*
  • Age range*
  • Tobacco use?*
  • Health status*
  • Do you have a monthly budget in mind?
  • Interested in annuities?
  • Should be Empty: