Assurance Plans Ai - Client Intake Questionnaire

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.

Gender :

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)?

Secret Answer :

If Custom Amount Yes

Do you currently have any insurance coverage?

Yes No Not sure

What is the primary reason you are seeking coverage?

Do you have a target monthly budget range for coverage?

Select your age :

20-29 30-39 40-49 50+

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.

Need to speak with a licensed professional?

If you’d like more information about indexed universal life insurance options available in your state, you can request to connect with a licensed insurance professional who can provide additional guidance and answer your questions.

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Get In Touch

Executive Office: 1000 Brickell Avenue
Suite 715 unit 351 Miami, FL 33131
Main Office: 786-345-7979
contact@assuranceplansai.com

Important Disclosure:
Assurance Plans AI is a marketing and information platform. We do not provide insurance advice or sell insurance products.

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Full Name:

Phone Number:

Email Address:

Which type of insurance have you taken from us?

🎉 Thank you — your licensed agent is being assigned. 🎉

Per the Assurance Plans AI Promise, only one licensed agent will contact you by your preferred method. No spam. No reselling. Expect a call/text from your agent shortly.

🎉 Thank You for Completing the Survey! 🎉

✅ Your responses have been received.
👩‍💼👨‍💼 An assigned licensed agent will contact you shortly to discuss your coverage needs.
🔒 Rest assured, your information is private and protected under the Assurance Plans AI Promise.

💙 We look forward to helping you secure the best and most affordable insurance plan for your future!

— The Assurance Plans AI Team 🛡️

Thank You!

We’ve received your information and our team at Assurance Plans AI will be reaching out to you shortly.

We’re excited to connect and help you get started on your journey to a 6-Figure Income in just 120 days!

Thank You for Your Inquiry!

Your request has been received by the Assurance Plans AI team.

A member of our support staff will contact you within 24 hours to confirm your interest and connect you with a licensed insurance agent. They’ll walk you through personalized plan options tailored to your goals, needs, and budget.

We’re honored you chose Assurance Plans AI — and we look forward to helping you secure the protection, security, and peace of mind you and your loved ones deserve.