What type of insurance coverage are you most interested in?

Life insurance (term or whole life)

Final expense/burial insurance

Health insurance (covers medical expenses)

Not sure yet, just exploring options

Who will this policy be for?

Myself

My spouse/partner

A parent or elderly relative

Someone else (child, grandparent, etc.)

How soon are you looking to get coverage?

Immediately

Within the next 30 days

In the next few months

Just gathering information for now

What level of coverage best fits your needs?

Less than $10,000 (typically for final expenses)

$10,000 - $25,000

$25,000 - $50,000

Over $50,000 (typically term/whole life coverage)

Do you currently have any life, final expense, or health insurance?

Yes, but I want to add more coverage

No, I don’t have any coverage

I have some coverage but want to switch or compare rates

I’m not sure what I need

Have you or the person considering applying had any major health conditions in the past 5 years?

No, generally in good health

Yes, but under medical management (e.g., diabetes, high blood pressure)

Yes, serious conditions (e.g., cancer, heart attack, stroke)

Not sure or prefer not to answer

What is your age range?

Under 50

50-60

61-70

Over 70

What is your preferred method of communication to discuss your options?

Phone call

Text message

Not sure yet

What is your biggest concern when choosing an insurance policy for yourself or your family?

Finding an affordable policy within my budget

Making sure my family is financially protected

Getting approved despite health conditions

Choosing the right type of policy (life, final expense, or health)

Would you like a FREE, no-pressure review of your coverage options by a licensed agent?

Yes, I’d love to see what’s available

I’m curious, but not ready yet

No thanks, not interested

What's the best way to reach you?

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