Initial intake form

Initial intake form

We understand the importance of your privacy and are committed to protecting your personal information. When you request a life insurance quote from us, we collect certain information to accurately assess your needs and provide suitable options. Your information is confidential: We will not share your personal information with any third party without your explicit consent, except as required by law. Providing accurate information is crucial for receiving accurate life insurance quotes. If any further questions, please email us at theharrisonbrokerage@Gmail.com
Customer Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
How did you hear about us?*
Please Specify*
Birthday

MonthDayYear
Height*
Weight*
Do you currently have any life insurance policies in place?*
Has your biological mother or father been diagnosed with Heart Disease, Cerebrovascular Disease, Cancer or Diabetes at or before age 70?*

YesNo
Have your biological sibling(s) been diagnosed with Heart Disease, Cerebrovascular Disease, Cancer or Diabetes at or before age 50?*

YesNo
Any major surgeries in the past 10 Years*

YesNo
If Yes, what were the surgeries?*
Do you take any medications? If Yes: please list the names and what they are for. *
Any diagnosis of anxiety or depression?*

YesNo
Tobacco categories*

SmokerChewing / Snuff / OtherNoneMarijuana
High cholesterol*

YesNo
COPD*

YesNo
High blood pressure*

YesNo
Heart conditions*

YesNo
Sleep apnea*

YesNo
Stroke*

YesNo
Cancer*

YesNo
Details about what type of cancer diagnosis and dates
Diabetes*

YesNo
Details about diabetes (Do you take insulin? What type of diabetes?)
Do you own your home or rent?*

OwnRentOther
Mortgage Amount
Monthly payment*
What type of coverage are you looking for*

Mortgage ProtectionFinal ExpenseDebt Free LifeTermUniversal LifeWhole LifeAccidental DeathCritical IllnessDisabilityReturn of PremiumChildrenSpouseUnsure
Schedule a time to chat more in depth about what you are looking for and for us to review your answers with you.
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