1 About You

Just the basics so we know who we're talking to.

First Name *

Last Name *

Phone *

Email

Date of Birth *

ZIP Code *

Preferred Language

English Español Both / Ambos

Best way to reach you

Call Text Email Any works

2 What Are You Looking For?

Select everything that applies — we'll walk you through the rest.

Life Insurance Term, whole life, final expense, IUL

Health Insurance ACA/Marketplace, private plans

Supplemental Critical illness, accident, disability

Medicare New to Medicare or reviewing current plan

Legacy Planning Family documents, final wishes, The Guide

Not Sure Yet Help me figure out what I need

3 Health & Family

This helps us find plans that actually fit your situation.

How would you describe your overall health? *

Excellent No major health issues Good Minor or managed issues Fair Some ongoing conditions Complex history Multiple or serious conditions

Do you use tobacco products?

No Yes Former smoker

Who needs coverage?

Just me Me + spouse/partner Whole family

Number of dependents (children)

0 children / dependents

Any pre-existing conditions we should know about?

Optional but helpful. This helps us match you with the right carriers. Health history may affect life insurance rates and eligibility — we'll always be upfront with you about what we find.

4 Budget & Timing

No wrong answers here — this just helps us find realistic options for you.

Monthly budget for coverage

Under $50/mo $50 – $100/mo $100 – $200/mo $200 – $300/mo $300+/mo Not sure yet

When are you looking to get covered?

ASAP Within 30 days 1–3 months Just exploring

Do you currently have any insurance?

No Yes, through employer Yes, private plan Had it, lapsed

Anything else you want us to know?

Let's find what fits your life.

We got your info.