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Prosper The Right Way - Client Intake Questionnaire

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This form is used to collect general information for review by a licensed insurance agent. Submission of this form does not constitute insurance advice, a quote, or coverage determination. A licensed agent will review the information and contact you to discuss available options.

Full Name :

Phone Number :

Email Address :

Preferred Method of Contact :

Phone Email Text

Best Time to Contact You :

Morning Afternoon Evening

State of Residence :

ZIP Code :

Which insurance categories would you like to receive information about?

Have you spoken with a licensed insurance agent recently?

Yes No

Are you requesting information for yourself, a business, or general education?

Personal Business General Information

When would you like to speak with a licensed agent?

As soon as available Within the next few days Next 1–2 weeks Just gathering information

What is your desired life insurance coverage amount (death benefit)?

$25,000 – $50,000 (Final Expenses / Basic Protection) $100,000 – $250,000 (Family & Income Protection) $500,000+ (Mortgage / Business / Estate Planning) Not sure yet — I’d like guidance from an agent Custom Amount

If Custom Amount Yes

Do you currently have any insurance coverage?

Yes No Not sure

If yes, which type(s)?

Life Health Annuity Disability Other

What is the primary reason you are seeking coverage?

Protect my family / dependents Cover final expenses Pay off mortgage or debts Replace income Business protection Estate planning

Do you have a target monthly budget range for coverage?

Under $50 $50 – $100 $100 – $200 $200+ Not sure yet

Who would you like to name as your primary beneficiary?

If something were to happen to you today, what would be your biggest financial concern for your family or business?

Is there anything specific you would like the licensed agent to be aware of before contacting you?

I understand this form is for informational and administrative purposes only.

I understand that no insurance advice, quotes, or recommendations are being provided at this stage.

I consent to be contacted by a licensed insurance agent for further discussion.

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Executive Office: 1000 Brickell Avenue
Suite 715 unit 467 Miami, FL 33131
Main Office: 786-345-7979

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Disclaimer :

Information provided is for educational purposes only and does not constitute insurance advice, a recommendation, or a guarantee of coverage. Availability, terms, and conditions vary by state and carrier. A licensed insurance agent can provide additional information upon request.

© 2018 - 2026 Prosper The Right Way. All Rights Reserved. Prosper The Right Way is a licensed Insurance Agent in the State of Florida. License No.W459794

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