Life Insurance Review

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Life Insurance Review* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Date of Birth* This field is required.
Date
Month
Day
Year
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What would you like to accomplish with life insurance at this stage of your life?* This field is required.
Protect family's income
Cover final expenses
Build a stronger financial plan
Learn how life insurance can be used while I am living
Plan for possible long-term care needs
I am not sure yet and I would like guidance
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The next few questions help me understand whether a personalized review may be appropriate for you. This is not an application, and no decisions are made at this stage.
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What is your height?
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What is your weight?
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Do you currently use tobacco or nicotine products?
Yes
No
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Have you ever been diagnosed with a major health condition?* This field is required.
YesNo
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If applicable, which of the following best describes your situation?
Heart condition
Diabetes
Cancer history
Stroke
Other
Not Applicable
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Thank you for sharing this information. This helps me guide you more accurately when we review your options together.
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What monthly amount would feel comfortable for a protection plan designed for you and your family?
Under $100 per month
$100 to $250 per month
$250 to $500 per month
$ 500 to $750 per month
More than $ 750 per month
I am not sure yet
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Would you like to learn how some life insurance options may allow access to benefits in case of a critical, chronic, or terminal illness?
Yes
I would like more information
Not at this time
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Have you considered how you would cover the cost of long-term care if needed?
Yes
I would like more information
Not at this time
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Many families are surprised to learn that long-term care is not fully covered by traditional health insurance or Medicare. Planning ahead can help protect your savings and provide more care options.
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How would you prefer to review your options with me?
In person
Video Call
Phone Call
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What time of day works best for you?
Morning
Afternoon
Evening
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Consent* This field is required.I understand this is not an application for insurance. Completing this form does not guarantee approval or coverage. I consent to be contacted by Janix Barbosa-Llanos to review possible options based on the information provided.
I understand this is not an application for insurance
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I look forward to personally reviewing your information and guiding you through your options.
— Janix Barbosa-Llanos, MBA, PMP, RSSA, FSN
Financial Security Navigator
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Please verify that you are human* This field is required.
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