Your Life Insurance
Client Intake Form

Welcome! Please complete all sections below. This helps us customize the right coverage for you and your family. Your information is kept private and secure.

Personal Information

First Name *

Middle Name

Last Name *

Date of Birth *

State of Birth

Gender

Marital Status

Social Security Number *

Citizenship

🪪 Driver's License / Government ID

Driver's License Number

Expiration Date

Issuing State

Contact Information

Phone Number *

Alternate Phone

Email Address *

Street Address

City

State

ZIP Code

Preferred Contact Method

📞 Phone Call

💬 Text

✉️ Email

Best Time to Reach You

Morning (8am–12pm)

Afternoon (12–5pm)

Evening (5–8pm)

Employment & Income

Employment Status

Occupation / Job Title

Employer Name

Annual Household Income

Health History

Height

Weight (lbs)

Tobacco / Nicotine Use

Have you ever been diagnosed with any of the following?

Diabetes

Heart Disease

Cancer (last 10 yrs)

Stroke / TIA

COPD / Emphysema

Kidney Disease

HIV / AIDS

Mental Illness

Drug / Alcohol Dependency

✓ None of the Above

Are you currently taking any medications?

List medications and conditions treated

Any hospitalizations or surgeries in the last 5 years?

Please describe

Family history of serious illness? (parents/siblings)

Please describe

🩺 Primary Care Physician

Physician's Full Name

Office Phone Number

Office / Practice Name

Office Address

Coverage Needs & Goals

What type of life insurance are you interested in?

Term Life

Whole Life

Final Expense

IUL (Indexed Universal)

Not Sure Yet

Desired Coverage Amount

Monthly Budget for Premiums

Primary reason for seeking coverage

Income Replacement

Funeral / Final Expenses

Debt Protection

Legacy / Wealth Transfer

Cash Value / Savings

Business Protection

Number of Dependents

Do you currently have life insurance elsewhere?

Current Carrier

Current Coverage Amount

How did you hear about Secure Shield Agency?

Beneficiary Information

Primary Beneficiary

Full Legal Name

Relationship

Date of Birth

Phone Number

% of Benefit

Contingent Beneficiary (optional)

Full Legal Name

Relationship

Date of Birth

Phone Number

% of Benefit

ACH / Bank Draft Authorization

Your banking information is submitted directly and securely to our encrypted CRM

Where to find your numbers:

RRouting # — first 9 digits at bottom left

AAccount # — middle set of numbers at bottom

You can also find these in your online banking or by calling your bank.

Bank Account Details

Account Holder Name *

Account Type

Bank / Financial Institution

Routing Number *

Account Number *

Confirm Account Number *

Draft Schedule

Preferred draft day of the month

1st

5th

10th

15th

20th

25th

Draft Frequency

Monthly

Quarterly

Semi-Annually

Annually

ACH Authorization: By completing and submitting this form, I authorize Secure Shield Agency and its designated insurance carriers to initiate ACH debit entries from the bank account listed above for premium payments according to the schedule selected. I understand I may revoke this authorization at any time by contacting my agent with 10 business days' notice.

I agree to the ACH authorization above and confirm the bank account information is accurate.

Review & Digital Signature

Your Signature *

Please sign in the box below using your mouse or finger.

Sign above

I certify that all information provided in this form is true and accurate to the best of my knowledge. I understand that providing false information may result in policy cancellation or denial of claims.

Thank You!

Your intake form has been received by Secure Shield Agency. Your agent will review your information and reach out to you within 1–2 business days to discuss your coverage options.

📞 Questions? Call or text us anytime.

Secure Shield Agency · Lakeisha Johnson, CEO & Principal Agent
South Carolina · North Carolina · Texas · "Where Protection Meets Prosperity"
Your information is kept private and submitted securely. We will never sell your data.

Your Life InsuranceClient Intake Form

Thank You!

Your Life Insurance
Client Intake Form