Life Insurance

Let's Protect What Matters Most

Tell us a little about yourself and your goals. Sabrina will reach out to start the conversation.

Important Notice: This form is a consultation request only — it is not an application for insurance coverage and does not bind coverage of any kind. Submission of this form does not guarantee the availability, price, or terms of any insurance product.

Licensed Insurance Producer Disclosure

Sabrina Benjamin-Bailey is a licensed insurance producer. License information is available upon request and on file with the applicable state insurance departments. Established Grace Enterprises operates in compliance with applicable state insurance laws.

Privacy Notice (GLBA)

The information you provide is collected under the Gramm-Leach-Bliley Act (GLBA) and applicable state privacy laws. Your non-public personal information (NPI) will be used solely to identify suitable insurance products and facilitate your consultation. It will not be sold to third parties. Health information you voluntarily share may be disclosed to insurance carriers solely for underwriting evaluation purposes, as permitted by law. You have the right to opt out of certain information sharing — contact us at info@establishedgrace.com to exercise this right.

Your Contact Information

How should we reach you?

First Name *

Last Name *

Email Address *

Phone Number *

Required for consultation scheduling

City

State of Residence

Used to verify producer licensure in your state

Preferred Contact Method

Best Time to Reach You

Anything you'd like Sabrina to know?

Optional — 100 characters max

0/100

What Best Describes Your Need?

Select the option that most closely matches your situation. This helps Sabrina prepare the right solutions for your consultation.

Health Snapshot

The following questions are asked solely to help identify carriers and products that may be suitable for your situation. You are not required to answer. Any health information you provide may be shared with insurance carriers for underwriting evaluation only.

These questions are voluntary and are used solely to help identify carriers and products that may be suitable for your situation. Answering does not constitute a formal insurance application. Any health information you provide may be shared with insurance carriers for underwriting evaluation only, as disclosed in the Privacy Notice above.

Tobacco or Nicotine Use in the Last 12 Months?

Any Major Health Conditions?

Authorizations & Disclosures

Please review and acknowledge each item below before submitting.

Required Authorizations

*I authorize Established Grace Enterprises and its licensed producers to contact me regarding insurance products and services using the contact information provided above.*I have read and acknowledge the Privacy Notice above. I understand that my non-public personal information may be shared with insurance carriers for underwriting purposes only.*I voluntarily provide the health information on this form and authorize its use for the sole purpose of identifying suitable insurance products. I understand this is not a medical record and does not constitute a health insurance application.*I agree to use electronic records and signatures in connection with this consultation request. I understand I may request a paper copy of this form and any related documents at no charge by contacting info@establishedgrace.com.

Optional — You may decline without affecting your consultation

I expressly consent to receive calls and/or text messages at the phone number provided, including via automated dialing systems or pre-recorded messages, for the purpose of discussing insurance products. Message and data rates may apply. I understand this consent is not a condition of purchasing any product or service, and I may revoke it at any time by contacting info@establishedgrace.com.I consent to receive informational and marketing emails from Established Grace Enterprises. I understand I may unsubscribe at any time.

By submitting this form, your electronic acknowledgments above will be recorded with a timestamp as required by the Electronic Signatures in Global and National Commerce Act (E-SIGN Act, 15 U.S.C. § 7001). You may request a paper copy of this form at any time by contacting info@establishedgrace.com.

Fields marked * in the authorizations section are required. Submission constitutes your electronic signature under the E-SIGN Act.