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Name
Required Name!
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DOB
Required DOB!
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Zip Code
Required Zip Code!
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Phone
Required Phone!
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Email
Required
Format invalid
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Preferred Contact
Call
Text
Email
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Who are we protecting?
Spouse/Partner
Children
Aging parent
Business/Key Employee
Other
Please select at least one item.
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If you selected Children above, how many?
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If you selected Other above, please elaborate:
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What are the top goals? (pick 1–3)
Income for family
Pay off mortgage
College funds
Final expenses
Leave a legacy
Business continuity
Build cash value
Other
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If you selected Other above, please elaborate
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Time horizon (how long should coverage last?)
10 years
20 years
30 years
Until mortgage ends
Lifetime
Not sure
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If you selected Until mortgage ends above, what year?
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Budget comfort (monthly)
<$50
$50–$100
$100–$200
$200–$400
Flexible with guidance
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Quick household snapshot
Provide as much information as you can
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Annual household income (approx):
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Savings/investments available if needed:
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Mortgage balance:
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Other debts (loans/credit):
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Existing life insurance (face amount):
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Employer life benefit (if any):
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Health checkpoint
(high level only)
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Tobacco/nicotine in last 12 months?
Yes
No
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Height: ft /in
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Weight
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Any major conditions diagnosed/treated in the last 5 years? (check any):
Heart
Stroke
Cancer
Diabetes
Sleep apnea
Mental health
Other
None
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If you. selected Other above, please elaborate
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Current medications (names only):
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Previously declined or rated for life insurance?
Yes
No
Not sure
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Anything else we should factor in? e.g., future college costs, caring for a family member, business buy sell, special needs trust, etc.