INTAKE FORM

You are communicating with Rip Curtis.

What type of coverage? *

This form will prompt you for personal information of the following nature:

- occupational

- financial (can be deferred)

- lifestyle (can be deferred)

- medical (can be deferred)

Why is this information necessary? Because risk factors determine what is available, at what cost, and what underwriting requirements will be called for. Since insurers have different risk tolerances, placement decisions are heavily influenced by personal information.

Not for enrollments.

To enroll someone, change your selection to Enrollment.

How would you prefer to do this? *

Let's talk (schedule a call)

On this form (It will take 10-20 minutes)

I have a quick question before getting started.

Are you the person to be insured? *

Yes

No. I represent someone else

What is your relationship with the person to be insured? *

I am his/her advisor (Financial Planner, Insurance Agent, etc.)

I am a Benefits Consultant

I am his/her Co-Worker

Other Other

What is your name? * 🛈

What is your e-mail address? * 🛈

From here on out, the term "you" refers to your client.

From here on out, the term "you" refers to the employee to be enrolled.

Where are you in the process? *

Looking into my options

Ready to apply

The information you provide on this form will be used to prepare the application kit.

Where in the process is the group? * 🛈

Just getting started

Ready to implement

Business Name *

Please use the legal name of the group, as this will be on the policy.