Thank You for Choosing us!Please fill out this customer intake form so that we may further assist you with your coverage needs. Name * First Name Last Name Date of Birth * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Social Security # * Driver's License Number * Height 4’7 4’8” 4’9” 4’10” 4’11” 5’0” 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’0” 6’1” 6’2” 6’3” 6’4” 6’5” 6’6 6’7” 6’8” 6’9” 6’10” 6’11” 7’0” Weight * Primary Care Physician * Your annual income (estimate) * $ Workplace/ Work phone Tax Dependents (Spouse, kids, etc..) * PLEASE LIST ALL or put NONE Beneficiaries (Life Insurance Only) Total annual household income (estimate) * $ Banking/payment info (Does not apply to marketplace/health plans or Medicare) Put ‘NONE’ if it does not apply. * * * * Current Prescribed Medication/ Special Notes * [Please list all medications] If none type ‘NONE’ ELECTRONIC SIGNATURE * I certify all the above information is accurate. I authorize True South Benefit Solutions -and parties calling on their behalf- To contact me about policy updates and for marketing purposes. These include but are not limited to: automated technology, SMS/MMS messages, and pre recorded/ AI generated messages. By typing my name below I understand that it is the same as if I signed a wet signature on paper, confirming that I have reviewed the above information. * Signature: Thank you!
