Terms & Conditions

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Terms & Conditions

Last updated: May 24, 2024

Read more about how Macy Insurance Solutions protects your information

Scripted Call Intake Form

Use this form while on the call to record key info, quotes, and client preferences. Everything auto-saves to the client profile!

Personal Information

First Name

Last Name

Phone

Email

Address

Street Address

City

State

Country

Country

Postal code

Family Life

Marital Status

Single
Married
Divorced
Widowed
Never Married
Civil Union
Other
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Spouse Name:

Spouse Date of Birth

Are you/ your spouse active or a veteran of the military?

Yes

No

Do you have children?

Yes

No

Children's Names & DOB

Do you want to include your spouse in your plan?

Yes

No

Coverage

Do you Currently Have Life Insurance

Yes

No

Amount of Coverage

$

How long have you had it?

Who is the policy with?

Are you replacing or adding coverage?

Replacing
Adding
unknown
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How much additional coverage?

Why is what you currently have not enough?

Have you looked into life insurance before?

Yes
No
A little
Other- Checks Notes for Explanation.
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How long have you been looking?

What have you found so far?

Why haven’t you moved forward?

What does "too expensive" mean to you?

If something happened tomorrow, do you have coverage?

Yes
No
Check Notes for Elaboration
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Who would be responsible for paying for your arrangements?

Would your family be able to come up with $10–$15k?

Yes
No
Check Notes for Elaboration
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Are you afraid that when you pass, if this is not taken care of, you will become a financial burden?

Is there a specific reason you're looking now?

Just in Case
Something Happened
Lost loved One Recently
Aging
Other- Check Notes for Elaboration
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Monthly Budget or Range

$

Preferred Coverage Amount

$

Types of Policies interested in:

Final Expense

Whole Life

IUL

Term

Not Sure

Medical

Height

Weight

Health Issues

Do you have cancer/cancer history or been asked by a doctor to be screened for cancer in past 2 years?

Yes
No
Screening Recommended
Other- Additional information in Client Notes
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Have you ever been diagnosed with HIV/AIDS

Yes
No
Unknown
Undetected
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Medications-

Application

Ready To Apply Today?

Yes
No
Maybe
Just wants a quote
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Beneficiary Name & Relationship

Are you Interested in any riders?

Recommended Carrier-

Quotes

Quote 1-
Quote 2-
Quote 3-

Client Notes

Looking for a First-Class Dental & Vision Insurance Consultant?

Schedule A Consultation

Macy Insurance Solutions is committed to serving you at the highest level with all your dental & vision insurance needs.

National Producer Number: 21305089

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Macy Insurance Solutions is committed to serving you at the highest level with all your dental & vision insurance needs.

National Producer Number: 21305089

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