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START MY BANK

Please complete the form below, and our team will contact you to discuss your needs and future. The form only takes a few minutes to complete.

Marital Status
Do You Have Children?

Basic Financial Questions

Are You Employed or Retired?
Do You Have Other Income Sources
Do You Save 10% or More?
Yes
No

Assets

Select the assets you have (select all that apply)

(Fill in the amounts below)

(Renters indicate monthly rent amount)

Do You Own Investment Property
Liabilities

(Select all that apply)

Have you ever filed for Bankruptcy?

Policy Information

Desired use for your new policy
Timeline to start your policy?
ASAP
1 Month
2 Months
3 Months+
TBD
Would you like to pay monthly or annually?
Monthly
Annually
TBD
Do you have life insurance?

Additional Information

Have you ever used nicotine?

This includes ANY nicotine product. (Cigarettes, Snus, Dip/Snuff, Cigars, Pipe Tobacco, Cigarillos, Inhalers, Patches, Gum, Lozenges, E-Cigarettes/Vapes of all types, Hookah, etc.)

Do you have primary physician?

If yes, all locations and dates required.

File Uploads

(Skip this part if you are using a phone.)

We only need the front of the license/ID. Medical records could reduce underwriting time by as much as 30 days. Call a team member for details at 770-727-4444

Just a few more things!

Have you read R. Nelson Nash's "Becoming Your Own Banker?"
Do you own one or more IBC® policies?
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