FORTIS CLIENT SERVICES

Life Insurance Intake Form

Answer a few quick questions so we can estimate your options and follow up with the best fit.

Before you start

No pressure. This helps us point you in the right direction. Final pricing can vary after underwriting.

Full Name

Age

State of Residence

Tobacco or nicotine use in the past 12 months?

Type of coverage interested in

Favorite color

Preferred contact method

Phone number

Email address

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Disclaimer: Final pricing may vary after underwriting.

Questions? Use Chat and we will take care of you.