Client Intake Form — Yvette Harris Insurance

Section 01

Personal Information

First Name *

Last Name *

Date of Birth *

Gender

Phone Number *

Email Address *

City & State *

Marital Status

SingleMarriedDivorcedWidowed

Do you have dependents?

Yes — childrenYes — spouse/partnerYes — parent/elderNo

Section 02

Insurance Needs

What type(s) of insurance are you interested in? *

Life InsuranceHealth InsuranceMedicare / SupplementDental & VisionDisability InsuranceFinal ExpenseAnnuity / RetirementNot sure — need guidance

Select all that apply.

Do you currently have insurance coverage?

Yes, through employerYes, individual planYes, MedicareNo coverage

What is your primary goal?

Protect my familyLower my premiumsFill coverage gapsPlan for retirementCover final expenses

Section 03

Health Information

How would you describe your overall health?

ExcellentGoodFairPoor

This helps determine eligibility and premium estimates.

Do you use tobacco or nicotine products?

NoYes — cigarettesYes — vaping/e-cigYes — otherFormer user

Do you have any pre-existing conditions?

NoYesPrefer not to say

Are you currently taking any prescription medications?

NoYes — 1 to 2Yes — 3 or more

Section 04

Financial Overview

Employment Status

Employed full-timeSelf-employedPart-timeRetiredUnemployed

Approximate Annual Household Income

Under $25k$25k – $50k$50k – $75k$75k – $100k$100k+Prefer not to say

Used only to help identify the most suitable plan options.

Monthly Budget for Insurance Premiums

Under $50$50 – $100$100 – $200$200 – $400$400+Not sure yet

Do you currently have any of the following?

Life insurance policy401(k) or IRAPensionSavings / emergency fundNone of the above

Select all that apply.

Section 05

Recent or Upcoming Life Events

Have you recently experienced or are you anticipating any of the following?

Marriage or divorceNew baby or adoptionBuying a homeJob change or lossRetirementLoss of a loved oneChild turning 26Aging parent needing careNone of the above

Select all that apply. This helps me time your coverage appropriately.

Anything else you'd like me to know about your situation?

Section 06

Contact Preferences

Best time to reach you

Morning (8am–12pm)Afternoon (12pm–5pm)Evening (5pm–8pm)Weekends onlyAnytime

Preferred contact method

Phone callText messageEmailVideo call

Select all that apply.

How did you hear about Yvette Harris Insurance?

Additional notes or questions for Yvette

Let's Protect What Matters Most