Life & Health Insurance Needs Assessment
Please complete this assessment so SCI Guidance can understand your needs and contact preferences. Follow the original PDF structure and answer only the questions that apply to you.
Contact Information
First Name
*
Last Name
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Please Select
Email
Phone
Text Message
Best Time to Contact You
Morning
Afternoon
Evening
Weekend
City
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code
*
How Did You Hear About SCI Guidance?
Please Select
Search Engine
Referral
Social Media
Advertisement
Event
Other
How Did You Hear About SCI Guidance? - Other
How Can We Help?
How can we help?
*
Life Insurance
Health Insurance
ACA Marketplace
Dental
Vision
Accident
Critical Illness
Hospital Indemnity
Final Expense
Mortgage Protection
Self-Employed Coverage
Business Owner Coverage
Employee Benefits
Group Health Insurance
Key Person Insurance
Buy-Sell Planning
Business Continuation
Review Existing Coverage
Not Sure
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Next
About You
Which best describes you?
*
Please Select
Individual
Family
Self-Employed
Business Owner
Employer
Retired
Other
Age Range
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Marital Status
Please Select
Single
Married
Domestic partnership
Separated
Divorced
Widowed
Other
Do you currently have life or health insurance?
*
Please Select
Yes
No
Number of children or dependents
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Next
Life Insurance
Do you currently have life insurance?
*
Yes
No
Which life insurance products are you interested in?
Term
Whole
Universal
IUL
Final Expense
Key Person
Buy-Sell
Not Sure
Additional notes for life insurance
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Next
Health Insurance
Do you currently have health insurance?
*
Yes
No
Which health coverage areas are you interested in?
Individual
Family
ACA
Self-Employed
Dental
Vision
Supplemental
Additional notes for health insurance
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Next
Business Solutions
Business Name
Industry
Employee Count
Which business solutions do you need?
Group Health
Employee Benefits
Owner Coverage
Dental & Vision
Voluntary Benefits
Key Person
Buy-Sell
Business Continuation
Executive Protection
Existing Benefits Review
Business goals and notes
Back
Next
Goals
Top priorities
Biggest concern
Questions you want answered
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Next
General age ranges of children or dependents
Do any dependents rely on you financially?
Please Select
Yes
No
Some
Unsure
Employment Status
*
Please Select
Employed full-time
Employed part-time
Self-employed
Unemployed
Student
Retired
Homemaker
Other
Date
*
-
Month
-
Day
Year
Date
Schedule Consultation
Schedule your free consultation!
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