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Home
About
Insurance Types
Insurance Guide
Contact
Refer A Friend
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Step
1
of 3
Gender
Male
Female
Other
Marital Status
Married
Single
Civil Partnership
Common-Law
Cohabiting
Divorced
Separated
Widowed
Next
What type of Insurance do you want?
*
Life Insurance
Auto Insurance
Property Insurance
Health Insurance
IUL
Annuity
Estate Planning
Debt Management
Do you already have an Insurance
Yes
No
Next
Cover Amount for Life Insurance
Policy Duration for Life Insurance
In the last 5 years have you had any of these?
*
Depression
Anxiety
Stress
Any Other Mental Health Issue
None of these
Have you ever had any of these?
*
Eating Disorder
Bipolar Disorder
Manic Depression
Schizophrenia
Psychosis
None of these
In the last 5 years have you had any of these?
*
Raised blood pressure, cholesterol, or chest pain
Diabetes or raised blood sugar
Anemia, blood clot, or anything else affecting your blood
A growth, lump, or cyst
Asthma, sleep apnoea, or anything else affecting your lungs or breathing
Kidney stones, urinary infection or anything else affecting your kidneys, prostate, bladder or urine
Back pain, sciatica, whiplash or anything else affecting your back or neck
Impaired, blurred or double vision, optic neuritis or anything else affecting your eyes
None of these
Cover Amount for IUL
Policy Duration for IUL
In the last 5 years have you had any of these?
*
High blood pressure, heart disease, or stroke
Diabetes or abnormal blood sugar
Cancer or tumor (benign or malignant)
Respiratory issues (e.g., asthma, COPD)
Digestive or liver disorders
Back, neck, or joint disorders
Anxiety, depression, or mental health conditions
HIV/AIDS or immune disorders
None of these
Do you smoke or use tobacco products?
Yes
No
Have you used any in the past 5 years?
Yes
No
Do you consume alcohol?
No
Occasionally
Frequently
Do you participate in hazardous sports or hobbies (e.g., skydiving, rock climbing)?
Yes
No
Cover Amount for Health Insurance
Policy Duration for Health Insurance
In the last 5 years have you had any of these?
*
High blood pressure or hypertension
High cholesterol
Diabetes or prediabetes
Asthma, COPD, or any chronic lung condition
Heart attack, stroke, or other heart-related conditions
Cancer or tumor (benign or malignant)
Digestive issues (e.g., Crohn’s disease, ulcer, IBS)
Back pain, arthritis, or joint disorders
Anxiety, depression, or other mental health conditions
None of these
Are you currently undergoing any treatment or taking regular medication for any of the following?
*
Blood pressure or cholesterol
Mental health (e.g., antidepressants, anxiety meds)
Insulin or diabetes medication
Pain management or anti-inflammatory medication
Other long-term medication
None
Do you smoke or use tobacco products?
Yes
No
Do you consume alcohol?
Yes, regularly
Occasionally
No
Do you engage in any high-risk activities or sports (e.g., skydiving, scuba diving)?
Yes
No
Cover Amount for Auto Insurance
*
Policy Duration for Auto Insurance
*
Vehicle Year
*
Vehicle Model
*
Do you own or lease this vehicle?
*
Own-paid in full
Own-making payments
Lease
What do you mostly use it for?
*
Personal/commuting
Pleasure
Farm
Business/rideshare
How many miles do you drive?
*
Cover Amount for Home Insurance
*
Policy Duration for Home Insurance
*
Who owns the property? (List everyone on the deed)
*
What is the address of the property you want to insure?
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
State
Zip Code
When was the property building/built?
*
What kind of property is it?
*
What is the square footage of the home?
*
Current Age:
Planned Retirement Age:
Do you currently receive retirement income (e.g., Social Security, pension)?
Yes
No
If yes, how much monthly (approx.):
When do you want income from your annuity to start?
How much are you considering putting into an annuity?
What are your primary goals for purchasing an annuity? (Check all that apply)
Guaranteed lifetime income
Wealth accumulation
Market participation with downside protection
Tax-deferred growth
Legacy planning or death benefit
Required Minimum Distribution (RMD) strategy
Long-term care coverage or income rider
Other
What is your current occupation?
What is the estimated total value of your estate (including property, investments, business interests, etc.)?
Do you own a business or have significant business assets?
Yes
No
Please describe
What are your goals for estate planning insurance?
Cover estate taxes
Preserve inheritance
Provide for dependents
Support a charity or foundation
Ensure smooth transfer of a business
Other
Please specify
Preferred coverage amount (if known)
Do you have any significant health issues or a history of serious illness?
Yes
No
Please specify
Employment Status:
Employed
Self-Employed
Unemployed
Retired
Other
Monthly Income (after taxes)
Total Monthly Expenses (including rent/mortgage, utilities, food, etc.)
Total Debt Amount
What types of debt do you currently have?
Credit Cards
Personal Loans
Medical Bills
Student Loans
Payday Loans
Auto Loans
Tax Debt
Other
Please specify
How many creditors do you owe money to?
Are you behind on any payments?
Yes
No
How many months behind?
What is your main financial goal?
Lower my monthly payments
Get out of debt faster
Stop collections
Student Loans
Avoid bankruptcy
Learn to budget
Other
Please specify
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