Fill in the details — your client securely enters one sensitive item
👤 Agent Information
🧑 Client Information
🛡️ Policy Information
🔒 What Do You Need From the Client?
🔒
Social Security #
SSN only
🏦
Banking Info
Routing & account
💳
Card Info
Debit / credit card
ℹ️ Optional: If you already have the client's routing number, enter it and the bank name auto-fills and locks on their form. Leave blank and the client fills it in.
✅Bank detected
✅ Your client will be asked to enter:
Please fill in all required fields marked with *
✅ Link Ready — Send to Client
🔒
Secure Application Form
Your information is encrypted and protected
Hi there,
Your agent has sent you this secure form to complete your application.
You're Applying For
—
Your Policy & Agent
🔒 Social Security Number
Please enter your Social Security Number below. This is required to complete your life insurance application.
🏦 Banking Information
Please enter your banking information below. This is used to set up your premium payment.
✅Bank detected
💳 Card Information
Please enter your debit or credit card details below. This is used to set up your premium payment.
Please fill in all required fields above.
🔒 256-bit encrypted · auto-deletes after 5 minutes
By submitting this form, you authorize your licensed insurance agent to use the information provided to complete your life insurance application with the carrier listed above.
✅
Information Submitted
Your information has been received securely. Your agent will follow up shortly to confirm your application details.
🔒 Security Notice
This page will permanently close in 5:00 to protect your information.
⚖️
Producer Data-Handling Attestation
REQUIRED BEFORE GENERATING A SECURE LINK
You are about to generate a secure link that collects a client's nonpublic personal information — which may include their Social Security number, bank account, or card details. Under federal and state law — including the Gramm-Leach-Bliley Act safeguarding requirements, applicable state insurance privacy regulations, and, for card data, the PCI-DSS standard — you are personally responsible for protecting it.
By proceeding, you attest that you will:
✓Use this information solely to complete this client's insurance application.
✓Keep it secure and never sell, share, or disclose it to any unauthorized party.
✓Permanently delete every copy of it immediately after the application is submitted.
You must check the box to attest before generating the link.
This secure form only transmits the client's entry to you and then auto-erases it. It keeps no copy. You are the sole custodian of the information once it is delivered.