Life Insurance Fact Finder

Tell us a little about what you’re looking for. This information helps us prepare for a more focused life insurance conversation and identify appropriate options to review with you.

Privacy note: Please do not submit Social Security numbers, bank information, account numbers, prescription lists, or detailed medical records through this form.

Contact Information

First Name *Last Name *Phone *Email *

Preferred Contact Method *Best Time to Contact *

Applicant Information

Date of Birth *Gender *State of Residence *Tobacco / Nicotine Use *Height *Weight *Occupation *

Coverage Goals

Coverage Amount Desired *Type of Coverage *Preferred Term Length if TermDesired Monthly Budget

Primary Purpose *

Income ReplacementMortgage ProtectionFinal ExpensesDebt ProtectionEstate PlanningBusiness NeedsSupplemental RetirementOther

Existing Life Insurance

Do You Currently Have Life Insurance? *

Current CarrierCurrent Coverage AmountCurrent Policy TypeAre You Replacing Existing Coverage? *

Health Snapshot

Overall Health *Any major health conditions in the last 10 years? *

If Yes, brief explanation

Any hospitalizations or surgeries in the last 5 years? *Family history of heart disease or cancer before age 60? *Any DUI or major moving violations in last 5 years? *

Beneficiary / Planning Context

Marital StatusNumber of DependentsBeneficiary RelationshipIs this coverage part of a retirement, estate, or business plan?

Additional Comments

Consent

I understand that submitting this request does not bind coverage and I agree to be contacted by Scordo Insurance Agency regarding this life insurance request.

Savings Without Compromise.

Get in Touch

1836 W. Virginia St, Suite 204
McKinney, TX 75069
Call: (469) 424-1980
Text: (469) 306-4171
Fax: (972) 793-8880

Start a Quote

Auto Insurance Quote
Home Insurance Quote
Commercial Quote
Life Insurance Quote

Company

About Us
Our Agents
Contact Page
Areas We Serve
Privacy Policy
Terms & Conditions