Plan Life With Robin

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Today’s Date

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Your Name Please * This field is required.My Name is Robin. I appreciate this opportunity to start a conversation about life financial needs!

Prefix

First Name

Middle Name

Last Name

Suffix

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Your State & Zip Code * This field is required.I need this to confirm I’m licensed to serve your life financial needs

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Your Date of Birth Please * This field is required.

Date

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Your Email* This field is required.

example@example.com

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Your Best Contact Number* This field is required.

Area Code

Phone Number

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What is your favorite color?This is for my security confirmation. I like knowing who I’m talking to when I return a future call. I will share my favorite color with you later!

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Why Get Coverage? This is One of the Most Important Questions to Asked Yourself. So please take your time.Examples: I Love My Spouse, I Love My Family, College For Children, Give Family Time To Make Decisions, I Love My Friends, Local Museum, Local Animal Shelter, Caregiver, Lawn Care Provider, Payoff Mortgage, Final Expense, Give To Charity, Retirement Planning, Long Term Care, Health Insurance Supplement, Vision Plans, etc

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Who would you say will take care of your future plans and their relationship to you?* This field is required.This is the Person You Would Trust as your Caregiver(s) Beneficiary(s), etc

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Which Are You Looking For - Choose An Option: (1)Whole Life (2)Universal Life (3)Index Universal Life (4)Term (5)Final Expense (6)Mortgage Protection Life Insurance (7)Index Annuity (8)Legal Plans (9)ID Protection (10)Long Term Care (11)Health Insurance Supplement (12)Vision Plan* This field is required.Please Type Your Option number(s) here

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Do you currently have insurance or anything that acts like insurance? * This field is required.Savings, IRA, Roth, Etc

YESNO

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Do you have life insurance on your job?If You’re Job Offer and You Have It- You are smart to have chosen. It’s also great to have personal coverage in place because most times group life Insurance usually isn’t convertible to the individual if they decide to leave a company.

YESNO

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What is your height* This field is required.Don’t Be Shy - Claim Every Inch

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What is your weight* This field is required.You Are Wonderfully Made

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When was last tobacco or nicotine use* This field is required.It’s Okay I’m Not Going To Report You to Tobacco Guards 🙊

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Cannabis Use in Last 12 Months * This field is required.No Judgement. I’m Just Looking For The Very Best Carrier 🥳

YESNO

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If your answer is YES to the above please share details here.* This field is required.Prescribed or Recreational Cannabis

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Take Your Time In This Space. Please Share if you have had COVID in the last year. List All Medicines prescribed, if Hospitalized with Dates. If Answer is No - Type N/A Below* This field is required. No Copy & Paste or Drag & Drop Please Clearly Type Information Below 🙏🏾

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Please List All Medical Conditions, Surgeries, Hospitalizations with Dates of Diagnosis. If None - Type N/A Below* This field is required. No Copy & Paste or Drag & Drop Please Clearly Type Information

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Please Gather Your Prescription Meds and List All You Take* This field is required. Sorry No Copy & Paste or Drag & Drop Please Clearly Type Information 🙃

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What is the life insurance face amount you would like for me to shop for? This is for our conversation when we speak. Also, please share your premium budget. This is the amount comfortable for your personal budget.

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Please Choose The Best Day and Time For Us to Talk

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Plan Life On Your Terms
Hi, I'm Robin Grayson a virtual licensed independent insurance broker for Alabama, Georgia, Michigan, Ohio and Texas. I have a partnership with some amazing carriers/companies to assist in creating your life insurance quote! When we talk we will discuss the premium budget and face amount of the insurance coverage that's comfortable for your budget.

I like to let my clients know, the carrier/company pay me directly. You will never pay me and should never pay any other representative directly. If an agent collects premium from you directly via cash, check, etc please contact the life carrier to report this activity. It's illegal.

Now, that I have shared that, I take this opportunity to shop for your personal coverage very serious. This is a great vehicle for you to use for financial planning as well as a ultimate statement of love to those you love.

The general information you provided in this form is for a insurance policy premium quote, which is non-binding.

As mentioned above, I would share my favorite color! It's green and this color reminds me to remain knowledgeable.

I am glad you are giving me this opportunity to assist you. I look forward to our conversation.

Thank you, Robin NPN 7653553

Please Note: The final insurance policy premium for any policy is determined by the insurance carrier/company underwriting department. Their bases is from the questions answered on the life insurance application submitted to them. By completing this form, this is not a submission for life insurance coverage with a carrier/company. This information wI'll help me find the best carrier/company for a Life Insurance Premium Quote Only. Also, you are giving me authority to communicate and contact you through email, text and phone calls.

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Sign Here* This field is required.To Acknowledge That You Have Read The Above Statement And Understand It

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