MHC Life Quote Survey

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Text Me: (318) 470-2537

Call Me: (318) 710-3668

Need Life Insurance? I can help!

Please complete this quick but informative survey which will walk you through the entire process of what we need to get you a quote or policy in place. Being detailed helps us.

Full Name *

Phone *

Address

Street Address

City

State

Postal code

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: *

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

By Submitting this Survey, I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from the company I am submitting this form to, Medicare Health Connections. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Life Quote Consent Signature

Clear

You have completed the survey. Please "SUBMIT" & our team will be notified. Allow 1-2 business days for us to process and contact you with the quote details. If you scheduled an appointment already, you should prepare to cover details on that call.

National Producer Number for MHC: 19169797

National Producer Number for Jeremy Patterson: 8827726

Jeremy Patterson and Medicare Health Connections is NOT AFFILIATED with and Government Agency.

We do not offer every plan available in your area. Currently we represent 10 organizations which offer 28 products 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) 470- 2537