LEGACY PROTECTION INTAKE
Time to create TRUST FUND HEIRS & Pass down assets for generations to come. Have a Trust? Life Protection is the #1 way to FUND that trust. Have a IUL Policy? Let's get it reviewed 80% of those policy benefit the agent not YOU the client.
Customer Details:
Full Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
How much can you afford to spend on life insurance monthly?
*
Have you ever been convicted of a felony?
*
If Yes, Please specify below:
Have you ever been charged for a DUI or DWI?
*
If Yes, Please specify date of charge & disposition:
Do you have a current bank account ? (Chime and Cash app UNACCEPTABLE)
*
Height
*
Example: 5”9
Weight
*
Example: 145 lbs
Describe any health issues:
*
Please be honest no discretion, medical records may be pulled if needed.
List any prescriptions you take or have taken in the past TEN years ! Enter N/A if none
*
Do you use Tobacco?
*
Yes
No
Previously, Yes
Occasionally
Are you employed?
Yes I have a job
I am a business owner
I work a job & own a business
I’m currently unemployed
If you answered yes, Enter name of employer & how long.
If you receive income, list your average monthly income amount in this box
*
Do you currently own an active life insurance policy?
*
Yes
No
I have insurance through my job
My parents have life insurance on me
Are you planning on cancelling any existing life insurance?
*
Yes
No
Do you have any investment accounts. High yield savings. Roth IRA, ect ?
*
Yes I do
No, but I’m interested
UPLOAD CURRENT POLICY IN PDF FOR REVIEW
Are you planning on adding children to your policy ? If so, how many ?
*
Please List ALL children you will be adding to your policy. Enter Date of birth next to the names. You may add any dependents ( children, grandchildren, nieces and nephews )
*
Are you married?
*
Yes
No
Going through divorce
Engaged
Our Meeting will take place via Zoom call. Your video is required to be on to verify I am speaking to the right applicant. I will be sharing my screen to explain the process and safely insert your information into our company’s portal.
I understand this zoom meeting requires my video to be on and for me to be in a quiet setting so that I am able to fully understand the process
What is the name of the agent assisting you with this Process ?
*
Please add any additional comments or questions:
Are you interested in being mentored to becoming a licensed agent? Manage Investments, Secure Mortgage License, Learn Trust Foundation?
I need to know how money work!
I'm not interested in making more money
I know someone who would be interested
Do you need any additional service?
Credit Repair
Business Credit
Family Lawyer
Mentorship
Not at the moment
Please provide names and numbers of anyone you can think of that could benefit from any of the services listed above, including life insurance:
*
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Full Name
Address
Contact Number
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