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You are communicating with Rip Curtis.
What type of coverage?
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Group (2 or more people)
Individual
Business (e.g., Key Person)
Executive
How would you prefer to do this?
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Let's talk
On this form (It will take 20-30 minutes, depending on health history)
I have a quick question before getting started.
Are you the person to be insured?
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Yes
No. I represent someone else
What is your relationship with the person to be insured?
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I am his/her Financial Advisor
I am his/her Insurance Agent or Benefits Consultant
I am his/her Co-Worker, Business Partner, or Assistant
Other
Other
An established client?
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Yes
No
What is your name? (not your client's)
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What is your e-mail address? (not your client's)
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Communication will be routed through you for now.
From here on out, the term "you" refers to your client because most of these questions relate to risk assessment of the person to be insured.
Where are you in the process?
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Looking into my options
Ready to apply
The information you provide on this form will be used to prepare the application kit. There will be another chance to finalize or change your answers after you finish this form.
Your client's client's contact information is not required as this stage.
Where in the process is the group?
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🛈
Just getting started
Ready to implement
Business Name
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Please use the legal name of the group, as this will be on the policy.