This Survey is separate from the giveaway. You DO NOT need to complete this form to be entered!

Are you over age 50? *

Many seniors haven’t heard about this program

and time may be running out!
Take this quick survey to find out if you’re eligible.

What will this plan cover? *

Burial

Cremation

Family

Who will benefit from this plan? *

Spouse

Child

Family

Other

First Name *

Last Name *

Email *

Year Of Birth *

Please Select Your State.

Zip Code *

Phone *

By clicking SUBMIT, I am providing my ESIGN signature and express written consent for Bright Benefits and its authorized partners or representatives to contact me at the phone number and/or email address I have provided for marketing purposes. This may include communication by phone call, text message, or email, and may be delivered using automated technology such as auto-dialers, pre-recorded messages, or other automated systems.

This consent applies even if my number is listed on a federal, state, or internal Do-Not-Call registry. I understand that my consent is not a condition of purchase.