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Message *

Life Benefits, LLC
Telephone: 702-660-7000
Email: [email protected]

Mailing Address:
35 E Horizon Ridge Pkwy #110-53
Henderson, NV 89002

Office Address:
1214 Addlyn Ct.
Henderson, NV 89002

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- Step 1 of 5

What's your #1 financial concern?

#1 financial concern:

What specifically is your concern with life insurance?

What specifically is your concern with your cash flow?

What specifically is your concern with your retirement?

What specifically is your concern with passive income?

What specifically is your concern with your taxes?

What specifically is your concern with your debt?

What type of debts do you currently have? (select all that apply)

Credit Card
Personal
Business
Student Loan
Mortgage
Vehicle

Credit Card debt details:

Personal debt details:

Business debt details:

Student Loan debt details:

Mortgage details:

Vehicle debt details:

Do you currently own life insurance?

Yes
No

Current Life Insurance details (as specific as possible)

Please include coverage amount, insurance company name, premium amount, type of policy (eg. Term, Whole Life, Universal Life ) etc.

...or you can upload your current policy illustration here

Click or drag a file to this area to upload.

Would you like to provide a few more details and get a quote for life insurance included with your plan?

Yes
No

Gender:

Male
Female

Height:

ft. in

Weight:

lbs

Birthdate:

Have you ever used tobacco nicotine or marijuana products?

Yes
No

Please describe what you use:

Please choose frequency of use:

Please describe use:

Occupation:

Do you own a business?

Yes
No

Business Name:

Income Amount:

Income Details:

Gross (before taxes)
Net (after taxes)

Income Frequency:

Annual
Monthly

Total Monthly Expenses:

Housing status:

Own
Rent
Mortgage

Rent payment per month:

Mortgage payment per month:

Additional notes on occupation and income and expenses

Do you have any investments?

Yes
No

Details about your investments:

Do you have any life insurance?

yes
no

Current Life Insurance details (as specific as possible)

Please include coverage amount, insurance company name, premium amount, type of policy (eg. Term, Whole Life, Universal Life ) etc.

Would you like to provide a few more details and get a quote for life insurance included with your plan?

Yes
No

Gender:

Male
Female

Height:

ft. in

Weight:

lbs

Birthdate:

Have you ever used tobacco nicotine or marijuana products?

Yes
No

Please describe what you use:

Please choose frequency of use:

Please describe use:

Do you have any of the following? (check all that apply)

401k
403b
SEP
IRA
Roth IRA
529 plan
Other

401k details:

Current balance, employer match details, current contribution amounts, etc.

Is this 401k with your current job?

Yes
No
Not sure

403b details:

Current balance, employer match details, current contribution amounts, etc.

Is this 403b with your current job?

Yes
No
Not sure

SEP details:

Current balance, current contribution amounts, etc.

IRA details:

Current balance, current contribution amounts, etc.

Roth IRA details:

Current balance, current contribution amounts, etc.

529 plan details:

Current balance, current contribution amounts, etc.

Other details:

What do you use for savings? (select all that apply)

Savings Account(s)
CD(s)
Permanent Life Insurance
Other
I don't have anything

Amount in Savings Account(s):

Details on CD(s)

Current balance, interest rate, years to maturity, etc.

Permanent life insurance details:

Name of Insurance Company, Type of Policy, Death Benefit amount, Cash Value accumulation, Premium amount

Other savings details:

Would you like us to send you our savings & budget planning tool?

Yes
No

Best email: *

Do You Have any debt?

yes
no

What type of debts do you currently have? (select all that apply)

Credit Card
Personal
Business
Student Loan
Mortgage
Vehicle

Debt details

amounts, interest rates, etc. (Please ad one debt type per line)

What are your financial goals?

Please share any questions you would like answered:

Name *

First

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

What is the best time and your preferred method of contact?

Comment

If you would prefer to provide these details over the phone, please call our office: 📞 702-660-7000
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