Who are we helping today?

Start with the basics. Name and phone are required.

First name

Last name

Mobile phone Email (optional)

Date of birth (optional)

Preferred language

English

Spanish

Marital status (optional)

Single

Married

Widowed

Divorced

First name, last name, and a valid phone are required.

Where do they live?

ZIP is required — it fills in the city automatically.

Street address (optional)

City

State

ZIP

Enter a 5-digit ZIP code.

What are we reviewing today?

Tap every line you want to cover. Only those sections will show.

Auto

Home / Property

Life

Health / Medicare

Pick at least one line to review.

Auto

Vehicles, drivers, and current coverage.

Vehicles

Drivers in household

1

2

3

4+

Insured right now?

Yes

No

Home / Property

The home we'd insure or review.

Own or rent?

Own

Rent

Property type

Single-family

Townhome

Condo

Mobile / Mfd

Year built

Approx. sq ft

Current home carrier (optional)

Est. value / dwelling

Mortgage?

Yes

No

Roof age (optional)

Life

Needs, health, and what they have now.

Dependents

0

1

2

3

4+

Annual household income (optional)

Tobacco / nicotine?

No

Yes

General health

Excellent

Good

Average

Poor

Existing life coverage (optional) Coverage they want (optional)

Product interest

Term

Whole

IUL

Final Exp.

Not sure

Health / Medicare

Current situation and what they take.

Medicare status

Under 65

Turning 65 soon

Has A & B

Part A only

Current coverage

Original Medicare

Advantage

Supplement

Employer

Marketplace

Medicaid

None

Not sure

Current plan / carrier (optional) Primary doctor (optional)

Prescriptions

0

1–3

4–6

7+

Preferred pharmacy (optional) Health conditions / notes (optional) Desired effective date (optional)

Notes & next steps

Anything to remember for the follow-up.

Best time to call

Morning

Afternoon

Evening

Anytime

Referral source (optional) Agent notes (optional)

Photo of ID or current policy (optional)

Where should this lead go?

Pick the GoHighLevel pipeline and the stage it lands in.

Pipeline

Stage

Review & save

Double-check with the client before saving.

By continuing, the client agrees that McAllen Insurance Group may contact them by phone, text, or email at the number and address provided regarding their insurance, including with automated technology. Consent is not a condition of purchase. Message and data rates may apply. Reply STOP to opt out.

✓

Intake saved

The lead sheet was sent to the office and saved. You can start a new one now.