WBC Intake Form — First Freedom Life

Personal Information

First Name *

Last Name *

Phone *

Email *

Date of Birth *

State *

Marital Status

Number of Dependents

Tobacco Use

Gender

Height

Weight (lbs)

Financial Snapshot

Annual Gross Income *

Income Type *

Employer Name

Monthly Mortgage / Rent

Total Monthly Debt Payments

Have a 401k / IRA / Retirement Account?

Approximate Retirement Balance

Monthly Amount Available to Reallocate *

Current Coverage

Do you have any existing life insurance?

Health Quick-Check

Any major health conditions?

Current medications?

Goals & Interests

What are you most interested in? *

Family Protection Cash Value Growth Become Your Own Bank Tax-Free Retirement Living Benefits Not Sure — Educate Me

Anything else we should know?

Preferred Meeting Time

Agent Use Only

Agent Name

Lead Source

Interest Level (1-10)

Agent Notes

🎯 Wealth Building Concept — Intake