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Fast intake

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This short intake helps us understand what you want to accomplish before we speak. It is not a formal insurance application and does not bind you to anything. Estimated time: about 3–5 minutes.

Contact

Business

Are you a business owner?

Goals

What are you hoping life insurance can help with? (select all that apply)

Coverage direction

Health (high level)

Tobacco or nicotine in the last 12 months?

Priorities

What is most important to you? (select up to 3)

Legal & disclosures

Expand any section to read in full. Complete the HIPAA acknowledgment before you submit.

Licensed insurance services

Insurance services are offered through Daniel Speiss, Licensed Life Insurance Agent (NIPR #1870781), licensed in New York, Florida, Texas, and Illinois (resident state: NY). Insurance services are available only to residents of those jurisdictions. Products may be placed via Crump Life Insurance Services through affiliation with Stone Press Financial Group.

This page is educational and for preliminary planning. It is not a formal life insurance application and does not bind coverage. Legal and tax questions require your attorney and CPA.

Before you enter health-related answers
  • Do not paste full medical records, account numbers, or Social Security numbers in any field.
  • Read the Notice of Privacy Practices in this section and check the acknowledgment box before you submit.

Notice of Privacy Practices - Health Information Protection

Important: Health-related answers on this preliminary intake (for example, how you describe your overall health or tobacco use) may be treated as Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA) when used to support insurance planning or a later formal application.

Expand full Notice of Privacy Practices, rights & contact

How we may use this information: We use it to understand your situation before we speak, to prepare recommendations, and—if you choose to apply—to support underwriting with carriers and authorized third parties as described in our full Notice.

  • Insurance carriers and their representatives, when you move forward with underwriting
  • Medical information bureaus and other authorized third parties, as permitted by law
  • Our affiliates and service providers who assist with applications and case processing

Your Rights: You have the right to:

  • Request access to your health information
  • Request amendments to your health information
  • Request restrictions on how we use or share your information
  • Request confidential communications
  • File a complaint if you believe your privacy rights have been violated

Our Responsibilities: We are required by law to maintain the privacy and security of your protected health information. We will notify you promptly if a breach occurs that may have compromised the privacy or security of your information.

For more detailed information about our privacy practices, please review our complete HIPAA Privacy Notice.

Privacy Officer Contact: If you have questions about our privacy practices or wish to file a complaint, please contact our Privacy Officer at [email protected] or by mail at the address provided in our full privacy notice.

Producer Compensation Disclosure

Tap to expand the full NY Regulation 194 disclosure.

Your Insurance Producer's Role: I, Daniel Speiss, am acting as your insurance producer (agent/broker) in this transaction. My role is to assist you in evaluating your insurance needs and to help you select appropriate insurance products that meet those needs.

Compensation: I will receive compensation from the insurance company or other third parties based, in whole or in part, on the sale of insurance products to you. This compensation may include commissions, bonuses, expense allowances, or other forms of remuneration.

Compensation May Vary: The compensation I receive may vary depending on a number of factors, including but not limited to:

  • The specific insurance product you select
  • The insurance company that issues the policy
  • The volume of business I provide to the insurer
  • The profitability of the insurance products I sell to the insurer
  • Other factors as determined by the insurer

Request Additional Information: You have the right to request detailed information about the compensation I expect to receive based on the sale of insurance products to you, as well as compensation I would receive for any alternative quotes I present to you. To request this information, please contact me directly or visit our detailed compensation disclosure page.

Notice: This disclosure is provided in accordance with New York Insurance Department Regulation 194. This disclosure applies to all insurance sales, including sales to residents of New York and sales of insurance products that will be delivered in New York.