GoldenCare’s Decline Placement Program

You’ve made the appointment, given the presentation, and closed the sale! ✔
Your client is comfortable with their decision and is feeling secure they will be covered in a health crisis. ✔

And then your client receives a decline letter.

Our GoldenCare Placement Team can help you get that client coverage and – most importantly –
maintain that strong relationship you worked so hard to build.

1. Fill out the form below

2. Watch your inbox for quote and client materials

3. Save that client sale!

Coverage for your client for virtually:

✔ Any Health Condition
✔ Any Budget
✔ Any State

GoldenCare will not contact your client directly, sell, or share your client information. We use all of the top carriers to match your client with the plan options customized for their health, budget and state. In the event you are not appointed with a carrier, we can help you get appointed or if you do not wish to be appointed with a carrier – with your permission – we can facilitate the sale and give you a generous fee. You’ll see on the form below, we do not even require their name!

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Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page: (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020). Important: Delete this tip before you publish the form.

Agent Name(Required)

First Last

Agent Email(Required)

Enter Email Confirm Email

Agent State(Required)

Agent Phone(Required)

Client State(Required)

Client Date of Birth(Required)

Client Marital Status

Client Gender

If client is married would you like a quote for spouse?

Please explain reason(s) for your client's decline and list any medications

Comments or special instructions for our Placement Team

Spouse health conditions / medications

Upload Decline Letter (Optional)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 32 MB.

Do you wish to share further information about your client or upload decline documentation?(Required)

Yes, I would like to share further information

No, I would like quoting based on the information provided above

Remember! GoldenCare will not speak with your client directly unless you specifically request and we will never sell or share their information.

Client Name

First Last

Client Email

Phone Number

Additional Client Details

I would like to automate my future decline processing

YES! Automate my declines.

For Assistance: 1-800-842-7799 • Career Opportunities

GoldenCare’s Decline Placement Program

Next Steps: Sync an Email Add-On

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