Agent-Led Client Intake Form

Referring Agent? *

Referring Agent Email *

Engagement Tier *

Client Information

First Name *

Last Name *

Phone *

Email *

State *

Is the client a homeowner? *

Owns additional real estate? *

Date of birth

Acknowledgments *

I confirm I have already signed the Agent Partnership Agreement.

I understand this Tier selection is final and cannot be changed after submission. Choice is per client.

I confirm this client has granted permission to be contacted by 1024 Wealth.

I understand that this client’s course access and case review will be linked to my Agent account.

I understand that if I am not appointed with the carrier, I will not be on the application and will receive payment directly from 1024 Wealth.

Client Privacy Commitment:
We are committed to protecting your client’s privacy and maintaining your trusted relationship. 1024 Wealth will not solicit your client for any product or service unrelated to this FLH and life insurance planning process.