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What’s your main goal for life insurance?
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Protect my family
Cover final expenses
Leave a legacy
Build cash value
I’m not sure
Who are you getting coverage for?
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Just myself
Me and my partner
Me and my kids
My parents
What’s your birth date?
*
First Name
*
Email
*
What’s your gender?
*
Male
Female
Do you currently have health insurance?
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Yes
No
In the last 2 years, have you used any THC products?
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Yes
No
Have you ever been convicted of a felony?
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Yes
No
Have you traveled outside the U.S. for more than 90 days in the past year?
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Yes
No
What’s your current zip code?
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Are you a U.S. citizen?
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Yes
No
Do you have a TIN Number?
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Yes
No
Not Applicable
Do you currently use tobacco or nicotine products?
*
Never used
Used in the past, but not currently
Occasionally use
Daily use
When are you looking to start your coverage?
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Immediately
In the next 30 days
Just browsing
What term length do you prefer?
*
10 years
20 years
30 years
Not sure
Are you currently working with a licensed agent?
*
Yes
No
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