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Insurance application form

To help us assist you in securing the right life insurance policy for your needs, please take a moment to fill out our form. This information will enable us to understand your specific requirements and preferences, ensuring we provide you with the most suitable options.

First Name

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On a scale of 1-5 how important is protecting your loved ones financially?

1. Just a 1. – currently, it's not my main financial focus. 2. Probably a 2. – there are more pressing financial matters. 3. It's a 3. – it's important but not the only thing I focus on. 4. I'd say 4. – very important but not my only concern. 5. Definitely a 5. – it's my highest priority.

For your insurance application, would you prefer Medical or Non Medical option?

1. Medical Option: Less expensive but will require a brief health examination conducted by a nurse, either at your home or the closest facility. 2. Non-Medical Option: Slightly higher rates but the non-medical insurance option offers quick, hassle-free coverage without the need for a health exam. 3. I would like to see rates for both.

I am interested in: Select All That Apply.

Whole Life Insurance. Term Life insurance. Critical Illness Coverage. Burial /Final Expense Insurance. I don't know the difference between whole life and term life insurance.

If insterested in term life insurance, for what length of term?

10 Year term 20 Year term 30 Year term I am not interested in term life insurance.

Coverage Amount? This can be changed later.

When was your Date of Birth

My height is

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When was the last time you used tabacco or a nicotine product?

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What's Your Why?

GET LYFE™ is a licensed insurance brokerage pioneering the financial realm through innovative fintech solutions. With a focus on life insurance, annuities, and financial education, GET LYFE™ seamlessly merges technology and finance, empowering users to make informed decisions, build legacies, and secure their futures. operating in the following states: North Carolina, South Carolina, Virginia, Tennessee, Oklahoma, Georgia, and Ohio. Our team of professional brokers is dedicated to providing exceptional service and tailored solutions to residents of these states. Please note that our services and advice are limited to the jurisdictions in which we are licensed.

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NPN Look-up

The NAIC provides expertise, data, and analysis for insurance commissioners to effectively regulate the insurance industry and protect consumers.

Step 1: Agent Verifier
All agents have passed state requirements and are legally licensed and insured for the sale of insurance products.
Step :2 View NPN Number
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You will need to enter Name and National Producer Number” NPN” of the GET LYFE Agent. on state regulated verifier.

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Insurance application form

What's Your Why?

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NPN Look-up

Step 1: Agent Verifier

Step :2 View NPN Number

Step 3: Select State to validate Agent