First Name *

Last Name *

Date of birth *

Phone *

Email *

State *

(These States ONLY) AZ, CA, FL, GA, HI, ME, MI, NC, TX, IL

What is your Health Status *

Ex. Cancer, Diabetes, Heart Disease, Etc.

What specific challenges are you looking to solve? *

Ex. Wealth Accumulation, Life Insurance Coverage, Estate Planning, Tax-free Retirement Income, etc.

What is your current income and do you expect it to change in the future *

Ex. $150k-$250k, $250k-$350k, $350k+

How much life insurance coverage do you need to replace lost income or cover specific expenses *

Ex. Mortgage, Living Expenses, College Tuition, Etc.

Existing Assets *

Ex. Stocks, Money Market, Other Life Insurance, Annuitites, Etc.

Account Assets will come from *

Ex. Checking and/or Savings account, Investment/Brokerage account, IRA, 401k

What financial obligations or debts do you have *

Ex. Mortgage, Credit Cards, Loans, Etc.

Have you already maximized contributions to other tax-advantaged retirement accounts *

Ex. 401k, Employee Retirement Accounts, IRA, Etc.

What is your risk tolerance *

Time Horizon-(If we find a product that solves the challenges you are currently facing) *

Ex. Now/Today, Within 30 Days, 3 Months, Months, etc.

Is there anyone else helping you make the decision to move forward *

Ex. Spouse, Kids, Financial Advisor, Relative, Other

Do you have any dependents *

Ex. Kids, Spouse, Relative, Other

By checking this box, I consent to receive non-marketing text messages from Global Wealth Consulting about Indexed Universal Life Products. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from Global Wealth Consulting at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.