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❤️JM CARDIO LIFE

Gut Health & More!

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Click Here For Our Gut Health!

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Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Name*

Phone*

Amount Desired

Check If Amount is to be determined

To Be Determined*

Date of birth*

Height*

Weight*(lbs)

Smoker*

Health Conditions*

Surgeries undergone in the past 12 months*

Email*

Message*

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Retirement Planning

Health INSURANCE REQUEST

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Vision Insurance Request

Retirement Planning

MEDICARE SUPPLEMENTS REQUEST

TRAVEL ASSURANCE REQUEST

College Funding

CANCER PLANS REQUEST

Retirement Planning

Pet Insurance Request

Pet Cremation Request

College Funding

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Retirement Planning Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

RETIREMENT PLANNING (#7)

1. Name

Last Name

2. Phone/Mobile

3. Email

4. Date of birth

5. Address

Address Line 1

Address Line 2

City

Zip Code

6. Do you have children?

If yes, do any of your children fall into the following age categories?

7. Do you have a Primary Doctor (Primary Care Physician)?

8. Do you smoke?

9. Do you have a 401(k) associated with a past employer that you are not gaining the benefits you desire for retirement?

10. Would you like to safeguard the money you’ve already invested from the uncertainty of the stock market?

11. Have you taken a look at your most recent 401(k) statement to value its recent performance?

Whether it's supporting your gut health and overall wellness or providing protection through our insurance plans, we're here every step of the way. Please feel free to click on any option below to learn more and schedule your free consultation.

Wellness Division: Gut Health at the Cellular Level & Holistic Approach

Medicare

Travel Protection

Final Expense

Mortgage Protection

College Funding

Vision Insurance

Term and Life Insurance

Dental Insurance

Health Insurance

Debt Relief

Cemetery

None

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Mortgage Protection Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

MORTGAGE PROTECTION

1. Name

2. Phone/Mobile

3. Email

4. Date of birth

5. Address

Address Line 1

City

Zip Code

6. Do you have children?

If yes, do any of your children fall into the following age categories?

7. Do you have a Primary Doctor (Primary Care Physician)?

8. Death Benefit Amount Desired

9. Check If Amount is to be determined

To Be Determined

10. Weight(lbs)

Height

11. Smoker?

12. Health Conditions

13. Surgeries undergone in the past 12 months

Whether it's supporting your gut health and overall wellness or providing protection through our insurance plans, we're here every step of the way. Please feel free to click on any option below to learn more and schedule your free consultation

Wellness Division: Gut Health at the Cellular Level & Holistic Approach

Medicare

Travel Protection

Final Expense

Retirement Planning

College Funding

Vision Insurance

Term and Life Insurance

Dental Insurance

Health Insurance

Debt Relief

Cemetery

None

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I consent to receive SMS notifications, Alert & Occasional Marketing Communication from Family Comes First. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

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College Funding Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

College Funding

1. Parents Name

2. Parents Phone/Mobile

3. Parents Email

4. Parents Date of Birth

5. Address

City

Zip Code

For the Parents:

6. Do you have a Primary Doctor (Primary Care Physician)?

7. Do you smoke?

8. Childrens Name

9. Monthly Payment Desired

Check If Amount is to be determined

To Be Determined

10. Child's Date of birth

11. Child's Height

12. Child's Weight(lbs)

13. Child's Health Conditions

8. If Child Undergorne Any Surgeries in the past 12 months

Whether it's supporting your gut health and overall wellness or providing protection through our insurance plans, we're here every step of the way. Please feel free to click on any option below to learn more and schedule your free consultation.

Wellness Division: Gut Health at the Cellular Level & Holistic Approach

Medicare

Travel Protection

Final Expense

Retirement Planning

Mortgage Protection

Vision Insurance

Term and Life Insurance

Dental Insurance

Health Insurance

Debt Relief

Cemetery

None

Consent Checkbox

I consent to receive SMS notifications, Alert & Occasional Marketing Communication from Family Comes First. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

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Ethos Life Insurance

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Name*

Phone*

Choose One

Date of birth*

Height*

Weight*(lbs)

Smoker*

Health Conditions*

Surgeries undergone in the past 12 months*

Email*

Message*

Debt Relief Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Debt Relief

1. First Name

Last Name

2. Phone/Mobile

3. Email

4. Date Of Birth

5. Do you have children?

If yes, do any of your children fall into the following age categories?

6. Smoker?

Do you have a Primary Doctor (Primary Care Physician)

7. Health Conditions

8. Are there any debts on which you're currently paying interest?

9. Are you paying extra money to pay off that debt?

10. If you were to become debt-free, in two short sentences, how would you use the money?

Whether it's supporting your gut health and overall wellness or providing protection through our insurance plans, we're here every step of the way. Please feel free to click on any option below to learn more and schedule your free consultation.

Wellness Division: Gut Health at the Cellular Level & Holistic Approach

Medicare

Travel Protection

Final Expense

Retirement Planning

Mortgage Protection

College Funding

Vision Insurance

Term and Life Insurance

Dental Insurance

Health Insurance

Cemetery

None

Consent Checkbox

I consent to receive SMS notifications, Alert & Occasional Marketing Communication from Family Comes First. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Terms and Conditions and Privacy Policy

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Final Expenses (Funeral Service: Cremation & Burial) Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Final Expenses (Funeral Service: Cremation & Burial)

1. First Name

Last Name

2. Phone/Mobile

3. Email

4. Date Of Birth

5. Do you have children?

Do you have a Primary Doctor (Primary Care Physician)?

Do you smoke?

6. Address

Address Line 1

City

State

Zip Code

7. Relationship to the Primary Applicant:

8. Choose plan

Burial (Cemetery)

Cremation

9. Are you currently receiving hospice care, or have you been diagnosed with or treated for a terminal illness or condition (other than HIV/AIDS) by a licensed member of the medical profession?

10. Are you currently bedridden, confined to a nursing home (including custodial care) or extended care facility, or have you been advised within the past 12 months by a medical practitioner that you should be so confined?

11. Within the last 36 months, has a medical practitioner diagnosed you with or treated you for, or have you taken medication for, any of the following? ( Cancer, Heart Disease, Coronary Artery Disease, Kidney Disorder, Liver Disorder, Lung Disorder, COPD, Brain Disorder, Blood Disorder, Circulatory Disorder, Stroke, Alzheimer’s, Nervous System Disorder, Aids, ARC (Aids Related Complex), HIV infection. )

Whether it's supporting your gut health and overall wellness or providing protection through our insurance plans, we're here every step of the way. Please feel free to click on any option below to learn more and schedule your free consultation.

Wellness Division: Gut Health at the Cellular Level & Holistic Approach

Medicare

Travel Protection

Retirement Planning

Mortgage Protection

College Funding

Vision Insurance

Term and Life Insurance

Dental Insurance

Health Insurance

Debt Relief

None

Consent Checkbox

I consent to receive SMS notifications, Alert & Occasional Marketing Communication from Family Comes First. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Terms and Conditions and Privacy Policy

All forms are the property of Family Comes First LLC and are protected by copyright and trademark laws. Unauthorized use, reproduction, or distribution of any material is strictly prohibited. All Rights Reserved.

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Health Insurance Questionnaire

Thank you for considering Family Comes First Insurance Agency for your insurance needs. To provide you with a customized health plan illustration, we kindly request the following information. We look forward to hearing from you soon. Thank you!

Health Insurance

Health Insurance

Your Individual & Family Health Plan Questions

Please provide the following information for each person in your household that you are applying for:

1. Primary Applicant's First Name:

Last Name:

2. Email:

3. Phone/Mobile

4. Date of Birth:

5. Address

City

State

Zip Code

6. Using Social Security/Itin#?

Health Information:

7. Do you have a Primary Doctor?

Do you smoke?

8. How often do you visit your doctor?

9. Do you take any medications?

If Yes, how often?

Employer and Coverage Details:

10. Does the employer offer a health group plan with 20 or more employees?

11. Have you experienced a loss of coverage within the past 60 days?

If yes, please provide the date when you lost coverage:

12. Are you applying for Individual or Family Plan?

What is your current employment status?

13. Marital Status:

Do you file taxes together or separately?

Net Income combined? Please put the $ amount

If Single, net income (previous year)?

13. Marital Status:

Do you file taxes together or separately?

Net Income combined? Please put the $ amount

If Single, net income (previous year)?

What's the reason why you're not adding your partner to this plan?

Family Household Member Information

Please provide the following information for ALL family members that you are applying for. Kindly put N/A if not applicable.

How many household members are you applying for?

Member 1. Name:

Date Of Birth:

Using Social Security/Itin #?

Marital Status:

Health Information:

Does this member have a Primary Doctor?

How often does this member visit the doctor?

Does this member take any medications?

If Yes, how often?

Member 2 Name:

Date of Birth:

Using Social Security/Itin #?

Marital Status:

Health Information:

Does this member have a Primary Doctor?

How often does this member visit the doctor?

Does this member take any medications?

If Yes, how often?

Member 3 Name:

Date of Birth

Using Social Security/Itin#?

Marital Status

Health Information:

Does this member have a Primary Doctor?

How often does this member visit the doctor?

Does this member take any medications?

If Yes, how often?

Member 4 Name:

Date of Birth

Using Social Security/Itin#?

Marital Status:

Health Information:

Does this member have a Primary Doctor?

How often does this member visit the doctor?

Does this member take any medications?

If Yes, how often?

Member 5 Name:

Date of Birth

Using Social Security/Itin#?

Marital Status:

Health Information:

Does this member have a Primary Doctor?

How often does this member visit the doctor?

Does this member take any medications?

If Yes, how often?

✅ If you are applying for 6+ household members, please number each member and keep them in order as you answer the next set of questions. This helps ensure all information is clearly organized for each member.

Names:

Date of Birth for each household member (MM/DD/YY):

Marital Status (Married, Single with Partner or Single)

Health Information:

For each household member, does this member have a Primary Doctor? Yes or No

For each household member, does this person take any medications? Yes or No

If Yes to Medications, how often? (Daily, Weekly, Monthly or Other)

First Name

Last Name

Company name

Email

Phone/Mobile

How Many Employees?

Do You Currently Have a Health Group Plan?

Are you interested in learning more about increasing employee paychecks, saving on payroll taxes, and potential refunds in the health group insurance plan?

Whether it's supporting your gut health and overall wellness or providing protection through our insurance plans, we're here every step of the way. Please feel free to click on any option below to learn more and schedule your free consultation.

Wellness Division: Gut Health at the Cellular Level & Holistic Approach

Medicare

Travel Protection

Final Expense

Retirement Planning

Mortgage Protection

College Funding

Vision Insurance

Term and Life Insurance

Dental Insurance

Debt Relief

Cemetery

None

Consent Checkbox

I consent to receive SMS notifications, Alert & Occasional Marketing Communication from Family Comes First. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Terms and Conditions and Privacy Policy

All forms are the property of Family Comes First LLC and are protected by copyright and trademark laws. Unauthorized use, reproduction, or distribution of any material is strictly prohibited. All Rights Reserved.

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Dental Insurance Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Dental Insurance

1. First Name

Last Name

2. Phone/Mobile

3. Email

4. Date Of Birth

5. Address

City

Zip Code

6. Do you have a Primary Doctor (Primary Care Physician)?

7. Do you smoke?

8. Do you have children?

If yes, do any of your children fall into the following age categories?

9. Do you have any dental or oral health conditions concerning your teeth?

Whether it's supporting your gut health and overall wellness or providing protection through our insurance plans, we're here every step of the way. Please feel free to click on any option below to learn more and schedule your free consultation

Wellness Division: Gut Health at the Cellular Level & Holistic Approach

Medicare

Travel Protection

Final Expense

Retirement Planning

Mortgage Protection

College Funding

Vision Insurance

Term and Life Insurance

Health Insurance

Debt Relief

Cemetery

None

**For family plans, some restrictions may apply.

Children must be under 26 years of age and living in the same household. If they are over 26, they can apply for their own plan.

Consent Checkbox

I consent to receive SMS notifications, Alert & Occasional Marketing Communication from Family Comes First. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Terms and Conditions and Privacy Policy

All forms are the property of Family Comes First LLC and are protected by copyright and trademark laws. Unauthorized use, reproduction, or distribution of any material is strictly prohibited. All Rights Reserved.

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Vision Insurance Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Vision Insurance

Vision Plan

Individual Plan

Family Plan

1. Primary Holder's First Name:

Last Name

2. Phone/Mobile

3. Email

4. Address

City

Zip Code

5. Date of Birth

6. Do you have a Primary Doctor (Primary Care Physician)?

7. Do you smoke?

8. Do you have children?

If yes, do any of your children fall into the following age categories?

9. Do you use glasses or contacts?

10.Please provide the name for each member and their age:

Whether it's supporting your gut health and overall wellness or providing protection through our insurance plans, we're here every step of the way. Please feel free to click on any option below to learn more and schedule your free consultation.

Wellness Division: Gut Health at the Cellular Level & Holistic Approach

Medicare

Travel Protection

Final Expense

Retirement Planning

Mortgage Protection

College Funding

Dental Insurance

Term and Life Insurance

Health Insurance

Debt Relief

Cemetery

None

** For family plans, some restrictions may apply.

Children must be under 26 years of age and living in the same household. If they are over 26, they can apply for their own plan.

Consent Checkbox

I consent to receive SMS notifications, Alert & Occasional Marketing Communication from Family Comes First. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Terms and Conditions and Privacy Policy

All forms are the property of Family Comes First LLC and are protected by copyright and trademark laws. Unauthorized use, reproduction, or distribution of any material is strictly prohibited. All Rights Reserved.

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Your Medicare Questionnaire

Hi, and welcome to your Medicare questionnaire! We’re so glad you’re here to start your Medicare journey with us. We’ll be more than happy to assist you every step of the way, ensuring you have a clear understanding—from reviewing your current plan to exploring new options that might benefit you in the coming year.

IMPORTANT!

To provide you with a complete and accurate comparison, We need both Part A and Part B on this form. We want to ensure that we have all the information organized in one place, as it allows us to give you the best possible support and guidance. Your needs are important to us, and having both parts will help us provide a complete overview. Thank you!

Please read through the entire email, as it contains VERY IMPORTANT information. I look forward to receiving your information soon.

Medicare

PART A.

1. Name of Beneficiary (Applicant)

Last Name

2. Email Address

3. Date Of Birth

4. Address

Address Line 1

City

State

Zip Code

5. Phone/Mobile

6. Do you have children?

If yes, do any of your children fall into the following age categories?

Do you smoke?

MEDICARE INFORMATION:

7. Do you have Medicaid?

Medicaid Card Number

8. Do you have VA or Tricare benefits?

VA

Tricare

None

9. Are you enrolled in Medicare?

Medicare Card Number (Please do not use hyphens or dash)

Effective date: Part A (Hospital)

Effective date: Part B (Medical)

Do you have any additional coverage, such as a supplement plan or a prescription drug plan? Select one or both, if applicable:

Supplement Plan (A, B, D, G, K, L, M, N, C, F)

Prescription Drug (Stand alone Plan)

None

Please provide the type of supplement plan and the monthly premium amount:

Please provide the monthly premium amount:

Would you like to provide an Emergency Contact?

If yes, please enter the name of your Emergency Contact:

Could you please share why you don't have Medicare coverage at this time?

Did you know you can get penalized? Don't risk unnecessary penalties! We're here to help you enroll and save!

VERY IMPORTANT:

To help us focus on your most important Medicare needs and to ensure your Medicare coverage aligns with your current healthcare or if you decide to change plans, please provide the following details:

✅ The following will further assist us in better understanding your needs.

10. What benefits are most important to you when it comes to your Medicare plan?

Please share any additional information you'd like us to know. This will greatly assist us in taking care of your needs.

PART B.

Doctors' Information:

✅ While we make every effort to ensure that your doctors and prescriptions are in-network at the time of enrollment for the upcoming year, please keep in mind that providers and prescription medications may move in and out of network throughout the year.

✅ If you find that any of your doctors or prescriptions are no longer covered, I recommend discussing it with your doctor's office to explore options for staying in-network. This will help protect you from unexpected costs and ensure continuous coverage.

11. How many doctors are currently involved in your care (MD's only)?

1. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

1. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

2. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

1. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

2. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

3. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

1. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

2. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

3. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

4. Doctor's Name

Type of Doctor

Type of Specialist

Doctor's Address

Address Line 1

City

State

Zip Code

For 5 or more, please list all the Doctors' names, addresses and types:

12. Do you take any medications?

Yes

No

13. How many prescription medications are you currently taking?

1. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

1. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

2.) Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

1. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

2. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

3. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

1. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

2. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

3. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

4. Type of Medication:

Dosage

Reason for Taking Medication:

Frequency

Form of Medication

For 5 or more, please list all your medications, dosages, reasons, frequency and forms:

Please indicate if there is a copay for any of your prescription medications and provide details of the amount if applicable.

Please still provide us with the name and address of a preferred pharmacy near your zip code so we can check if it’s in network and ensure your protection, should you ever need it in the future.

Pharmacy Name

Pharmacy Address

Preferred Pharmacy and Address:

Is it a Digital Pharmacy?

Pharmacy Name

Pharmacy Name

Pharmacy Address

Whether it’s wellness or protection, we’re here every step of the way to help you explore options that support your family’s well-being. Please feel free to click on any option below to learn more and schedule your free consultation.

Wellness Division: Gut Health at the Cellular Level & Holistic Approach

Travel Protection

Final Expense

Retirement Planning

Mortgage Protection

College Funding

Vision Insurance

Term and Life Insurance

Dental Insurance

Health Insurance

Debt Relief

Cemetery

None

✅**If you have already completed or scheduled your Medicare Comparison Overview Appointment, please disregard the following information.

✅**Once we receive your information, please expect a response within 24 hours to schedule your Medicare Comparison Overview Appointment with me or one of my experts.

✅Please be advised that once your Medicare profile is completed with the information you provided, a Scope of Appointment (SOA) form will be sent to you via email. This form must be signed and returned before we can discuss any details of your Medicare plan in order to comply with CMS requirements. This step ensures that we, as agents, provide you with proper care when explaining your plans and options.

✅Thank you for your consideration; we truly appreciate it! If you have any questions, please let us know. We are here to assist you in any way we can.

☆ At Family Comes First Insurance Agency, your privacy is important to us, and we are committed to assisting you while protecting your personal information, as stated under HIPAA client protection. By providing your personal information, you consent to us contacting you for your insurance needs, including answering your questions, reviewing insurance plans, and providing quotes for the plans you choose. Once we apply for your chosen insurance plan and you are approved, we will share your details with the specific insurance carrier.

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I consent to receive SMS notifications, Alert & Occasional Marketing Communication from Family Comes First. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Terms and Conditions and Privacy Policy

All forms are the property of Family Comes First LLC and are protected by copyright and trademark laws. Unauthorized use, reproduction, or distribution of any material is strictly prohibited. All Rights Reserved.

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Travel Protection Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Out of area protection - Travel Protection

Travel Protection

1. First Name

Last Name

2. Phone/Mobile

3. Email

4. Do you have children?

If yes, do any of your children fall into the following age categories?

5. Date Of Birth

Do you smoke?

Do you have a Primary Doctor (Primary Care Physician)

6. State of Residence

7. Total Trip Cost:

8. Destination

9. Departure Date

10. Return Date

11. Initial Deposit Date

Whether it's supporting your gut health and overall wellness or providing protection through our insurance plans, we're here every step of the way. Please feel free to click on any option below to learn more and schedule your free consultation

Wellness Division: Gut Health at the Cellular Level & Holistic Approach

Medicare

Final Expense

Retirement Planning

Mortgage Protection

College Funding

Vision Insurance

Term and Life Insurance

Dental Insurance

Health Insurance

Debt Relief

Cemetery

None

Consent Checkbox

I consent to receive SMS notifications, Alert & Occasional Marketing Communication from Family Comes First. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Terms and Conditions and Privacy Policy

All forms are the property of Family Comes First LLC and are protected by copyright and trademark laws. Unauthorized use, reproduction, or distribution of any material is strictly prohibited. All Rights Reserved.

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Cancer Plans Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Cancer PLANS

1. First Name

Last Name

2. Phone/Mobile

3. Email

4. Date Of Birth

5. Address

City

Zip Code

6. Do you have a Primary Doctor (Primary Care Physician)?

7. Do you smoke?

8. Do you have children?

If yes, do any of your children fall into the following age categories?

9. Have you undergone cancer treatments in the past and currently remain cancer-free?

10. Do you have a family history of cancer?

11. What is the reason for your interest in applying for a cancer plan?

Whether it’s wellness and protection, we’re here every step of the way to help you explore options that support your family’s well-being. Please feel free to click on any option below to learn more and schedule your free consultation.

Medicare

Travel Protection

Final Expense

Retirement Planning

Mortgage Protection

College Funding

Vision Insurance

Term and Life Insurance

Dental Insurance

Health Insurance

Debt Relief

Cemetery

Wellness Division (A holistic approach to fitness, beauty, & health)

None

Consent Checkbox

I consent to receive SMS notifications, Alert & Occasional Marketing Communication from Family Comes First. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Terms and Conditions and Privacy Policy

All forms are the property of Family Comes First LLC and are protected by copyright and trademark laws. Unauthorized use, reproduction, or distribution of any material is strictly prohibited. All Rights Reserved.

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Pet Insurance Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Pet INSURANCE

1. First Name

Last Name

2. Phone/Mobile

3. Email

4. Do you have children?

If yes, do any of your children fall into the following age categories?

5. Pet Name

Pet Breed

6. Gender Of Pet

7. Age

8. Weight

We’re here to help you find the best insurance for your needs! Here’s a quick overview of the plans we offer. Are you interested in learning more or have questions about any of these? Please select all that apply.

Medicare

Travel Protection

Debt Relief

Final Expense

Retirement Planning

Mortgage Protection

College Funding

Vision Insurance

Dental Insurance

Health Insurance

Cancer Plans

None

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Pet Cremation

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Pet Cremation

Pet Name

Pet Breed

Gender Of Pet

Age

Weight

Pet Cremation with Service

Owner First Name

Owner Last Name

Phone/Mobile

Email