Client intake form

Please complete all required fields. Select every product you'd like to learn about and we'll tailor your questions accordingly.

Personal information

Full name *

Age *

Sex *

Products of interest *

Life insurance Long term care Retirement (annuity) Life settlement

Please select at least one product.

Health & coverage

Height

Weight

Existing coverage

Do you use tobacco, nicotine, marijuana, or vape?

Yes No

Do you have any diagnoses or medical conditions?

Yes No

Have you been hospitalized in the past 12 months?

Yes No

Have you had surgery in the past 24 months?

Yes No

Activities of daily living Long term care

In the past 24 months, did you need assistance or supervision with any of the following?

Taking medications Toileting Walking Bathing Bowel or bladder control Dressing Eating Moving in/out of chair or bed

Retirement & annuity

What retirement accounts do you currently have?

List all account types you currently hold

Are you interested in guaranteed lifetime income?

Yes No Not sure

Desired monthly retirement income

When do you plan to retire?

Do you have any existing annuities?

Yes No

Please describe your existing annuities

Life settlement Policy details

What type of policy do you own?

Who is the insurance carrier?

What is the death benefit amount?

How long have you owned the policy?

Do you know the policy's cash surrender value?

Yes No

Cash surrender value

Have you been diagnosed with any chronic or serious medical conditions?

Yes No

Please describe your condition(s)

✓

Form submitted

Thank you! We've received your information and will be in touch shortly.

CA Insurance No. 6011901