Intake Form

How prepared are you for covering both expected and unexpected medical costs as you age?

WELL PREPARED– I have a solid plan for healthcare, long-term care, and unexpected expenses.

SOMEWHAT PREPARED – I have some coverage, but I’m unsure if it’s enough.

UNCERTAIN – I’m not sure how much I’ll need or what my options are.

CONCERNED – I worry that medical costs could drain my savings.

NO PLAN AT ALL – I haven’t planned for future healthcare expenses.

Which of the following are most important to you in retirement planning? (Select all that apply)

Mitigating Downside Risk

Ensuring Lifetime Income

Covering Future Medical Costs

Maximizing Growth Potential

Leaving a Meaningful Legacy

I Need Help with All of the Above

First Name *

Last Name *

Email *

Phone *

Age *

Mailing Address *

State *

Zip Code *

Approximately how much is your liquid net worth?

Less than $250,000

$250,000 - $500,000

$500,000 - $1,000,000

$1,000,000 - $3,000,000

$3,000,000+

Is there anything specific you’d like to discuss?

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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