Insurance Intake Form

Contact

Where we reach you with the game plan.

Full name *

Email *

Phone *

Agency Profile

Who you are and the scale you operate at.

1. What's the name of your agency? *

2. What is the size of your downline? * Upload proof of documentationANY FILE FORMAT

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3. On a monthly basis, how many writing agents do you have? * Upload proof of documentationANY FILE FORMAT

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Production

Documentation strengthens the negotiation.

4. What's your EOY production for 2025? * Upload proof of documentationANY FILE FORMAT

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5. What's your YTD production for 2026? * Upload proof of documentationANY FILE FORMAT

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6. In percentages, what products does your agency sell? *

e.g. Final Expense 90%, IUL 10%

7. Who is your current IMO/FMO/BGA?

List all that apply.

8. What's your current comp level? Optional: Upload documents pertaining to current comp grids / pay structureOPTIONAL

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Debt & Vectors

Answer straight — this determines what's negotiable and what needs a game plan first.

9. Do you have any outstanding debt? *

Yes No

If yes — how much? Upload documentation for debtANY FILE FORMAT

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10. Do you have any current Vectors? *

If yes, explain — and include any resolution game plans to remove them.

Yes No

Explain, including your resolution game plan Upload documentationANY FILE FORMAT

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Support & Comp

What you want out of the deal shapes what we go get.

11. Are you looking for mentorship, or are you self-sufficient? *

Looking for mentorship Self-sufficient A mix of both

12. Does comp level matter more than support, or are you looking for more support? *

Comp matters more Support matters more Balanced

13. We have an enterprise deal with InsuraCentral — an all-in-one engine for agency owners and agents. Would you like this paid for, or would you like to pay for it yourself? *

A free trial will be provided before committing. Your answer affects comp level.

Paid for I'll pay myself Trial first

Leads

How your agency feeds itself.

14. Do you have your own lead system in place, or do you buy leads? *

Own system Buy leads Both

15. Do you have a problem sourcing leads for your agents? *

Yes No

Pain Points

The honest version. This is where the negotiation strategy starts.

16. If you had to describe your biggest pain points as an agency owner, what would they be? *