REFERRAL INTAKE

Submit a Capitalis® referral

Provide the partner and opportunity information needed to create a new Capitalis® referral record.

Partner or Advisor Full Name

Firm or Organization

Business Email

Business Phone

Policyholder Full Name

Policyholder State

Relationship to Partner

Existing Carrier if known

Estimated Policy Face Amount if known

Opportunity Summary

I confirm that I am authorized to submit this referral information for review.

Do not include Social Security numbers, banking details, medical records, passwords, or account credentials in this form.

Your referral details are captured as a new Capitalis® record.

The referral information is reviewed for completeness and routing.

You can return to the Capitalis® portal to check the referral status.