Client Intake | Submit a Case

Section 01

Your Information

Your Full Name

Your Email

Your Phone

Your Relationship to Client

Section 02

Client Information

Client First Name *

Client Last Name *

Client Email *

Client Phone *

Date of Birth *

State *

Gender (for underwriting purposes) *

Survivorship (Second-to-Die) Policy?

Section 03

Health Profile

Overall Health *

Tobacco / Nicotine Use (Last 5 Years) *

DUI / License Suspension (Last 5 Years) *

Any Known Medical Factors That May Materially Impact Life Insurance Underwriting? (optional)

Any Medications Taken Regularly? (optional)

For preliminary assessment only. Do not include medical records. Formal details will only be collected if the case proceeds to underwriting.

Section 04

Financial Profile

Annual Income *

Net Worth *

Liquid Assets (excl. retirement accounts) *

401k / IRA Contributions?

Estimated Credit Score Range *

Existing Life Insurance

Carrier + Face Amount (optional)

Section 05

Case Goals

Main Objective *

Target Annual Tax-Advantaged Income

Target Retirement Age

Death Benefit Target

Open to Premium Finance / Structured Leverage? *

Additional Comments (optional)

Reviewed within 24–48 hours

✓

Submission received.

We'll review the details and be in touch within 24–48 hours.
Thank you for the referral.