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With LeadExchange™ working for you, you'll have confidence that the leads that your web site produces are only from interested consumers.  Below you'll find a sample Life Insurance lead.  All consumers are required to fill out a standardized questionnaire in order to be considered a valid lead.  To return, please click here

Do You Really Need Life Insurance?

If there is someone who would suffer economic hardship if you died, then the answer is yes... you need life insurance!   Whatsmore, some forms of life insurance can do more than simply cover your family, they can provide woderful retirement options as well!

Instructions:  Please fill in this form as completely as possible in order to ensure that your quote will be as accurate as possible.

E-mail Address


Who is this quote for?




Birthday (mm/dd/yy)



 feet inches



How much insurance
do you want?


What type of insurance
do you want?


How long do you want
coverage for?


Purpose of insurance:


Amount of insurance
in force now:


How much are you currently
paying per year?


When did you last
apply for insurance?


To which companies?
(please separate with commas)


What was the outcome?


Please indicate tobacco use:


Please describe your
particular health problems:
(leave blank if none)


Please list any medications
and dosage
(leave blank if none)


Describe your family's history
of cancer and/or heart disease
(leave blank if none)


First Name


Last Name


Street Address






Zip Code


Day Phone


Evening Phone


Preferred contact time?


Would you like an additional quote for any of the following insurance products?

 Annuities (Retirement Vehicle)
 Disability Insurance
 Long Term Care Insurance
 Health Insurance
 Group Health Insurance
 Auto Insurance
 Homeowners Insurance
 Home Loans