What are you main financial concerns? (Select all that Apply) *

Building Wealth

Eliminating Debt

Leaving a Legacy

Protecting my Lifestyle

Are you currently saving for retirement? *

Yes

No

Are you over $10,000 in debt? *

Yes

No

Do you have any existing life insurance? *

Yes

No

Annual Household Income *

Less than $50,000

$50,000-$100,000

$100,000-$250,000

$250,000-$500,000

More than $500,000

How would you rate your health? *

Excellent (Free from chronic health conditions, 0 medications prescribed)

Very Good (No major health concerns; minor issues (if any) are well-managed)

Good (Some minor health issues, no more than 3 medications prescribed)

Fair (One or more chronic health issues are present but managed)

Poor (Multiple chronic health conditions not manage)

Have you ever been diagnosed with any of the following health conditions? (Select all that apply)

Heart disease

High blood pressure

Diabetes

Cancer

Respiratory conditions

Neurological conditions

Mental health conditions

Other

None

What State do you live in? *

How old are you? *

What's your name? *

What's your email address? *

What's the best phone number to reach you at? *

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