Need help?

If You Answer "YES" to These 5 Questions, You Need Life Insurance

Do you have any dependents who rely on your income? *

Yes I have loved ones I need to protect

No, I do not have anyone who depends on my income

Do you have any outstanding debts (e.g., mortgage, car loans, credit card debt) that would burden your family if you passed away? *

Yes, I have debts that would burden my loved ones

No, I currently do not have any debts

Are you the primary income earner in your household? *

Yes, I am the primary income source for my household

No, I am not the primary income source or my spouse is the primary income source

Do you want to leave a financial legacy or cover funeral expenses for your loved ones? *

Yes, I would like to leave a financial legacy to my loved ones

I have no interest in leaving behind a financial legacy

Do you own a business that would be affected by your death? *

Yes, I own a business that would be affected by my death

No, I do not own a business or it would be unaffected by my passing

If you answered "YES" to any of the above, we recommend a quote from a licensed agent. Would you like a no-hassle quote on a life insurance policy to see if you qualify? *

Yes, please provide me a quote for life insurance

No thank you, I am not interested in a life insurance quote at this time

Full Name *

Email *

Phone *

Do you have any life insurance currently in place?

Yes, I have insurance through my employer

Yes, I have insurance outside of my employer

No, I currently do not have any life insurance

What is your gender?

Male

Female

Other

What is your date of birth?

What is your height?

What is your current weight?

Do you have any pre-existing medical conditions? If yes, please specify.

Are you currently or have you used tobacco in the last 12 months?

Yes

Do you engage in any high-risk hobbies or activities?

Yes I do participate in high-risk hobbies or activities

No, I do not participate in any high-risk hobbies or activities

What is your occupation?

What is your estimated household income?

How much life insurance do you believe you need?

Do you have a spouse who also needs life insurance protection?

Yes, please quote my spouse as well

No spouse to insure

What type of life insurance are you interested in?

Term Life Insurance

Whole Life Insurance

Universal Life Insurance

Not Sure (Need More Information)

If interested in term life insurance, what term length are you considering?

10 Years

20 Years

30 Years

Unsure

Are you interested in any additional riders or benefits, such as:

Accidental Death Benefits

Disability Income Rider

Critical Illness Rider

Long-Term Care Rider

General Rider Interest

What is your preferred payment frequency?

Monthly

Quarterly

Semi-Annually

Annually

When is the best time to contact you?

Mornings

Afternoons

Anytime During the Day

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Life Quote Consent Signature

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Licensed in the following states: LA, TX, AR, MS

National Producer Number for Jenna Justice: 19558828

Medicare Health Connections is NOT AFFILIATED with any Government Agency.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-Medicare, or your local state health insurance program, (SHIP) to get more information on your options.

(318) 450-6450