Intake form

Help us serve you better

Name *

Email address *

What type of insurance are you interested in?

Please select at least one option.

Individual life insurance

Annuities

Long-term care insurance

Group benefits

Are you a business owner or an employee?

Please specify the nature of your cannabis-related business.

What is your estimated annual revenue?

What is your preferred method of contact?

What is your location?

Do you currently have any existing insurance policies?

If yes, please provide details about your current insurance policies.

Additional questions or comments

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