Life Insurance Needs Analysis Form

Family Financial Needs Questionnaire

All clients of the Brady Ingle Agency are required to complete a Life Insurance Needs Analysis. It is a simple form that lets you know how much coverage your family needs to have if something were to happen to you. There are only 4 questions. At the end of the form, you will have the option to answer some health questions if you are interested in a quote for coverage for your family or you may submit the Life Insurance Needs Analysis form without requesting a quote. If you have any questions, just give us a call at 972-475-2408.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How much would it take to pay off your mortgage?
This is most peoples largest debt. Paying this off for your family if something happened to you would put them in a much better situation.
How much would it take to pay off any other debt you may have like, Auto loans, credit cards, etc.
It's a good idea to take care of all of these things too. You wouldn't want to leave this debt behind to be a burden on your family.
What is your annual household income?
If something were to happen to you, your income will disappear immediately. Your remaining family then has two choices that they are faced with immediately, either make more money or live on less, and they can't do that overnight. They need time to adjust and figure their finances out. Life insurance experts recommend that families have 10 years of income replacement.
How many children do you have?
Typically, we recommend $100,000 in Life Insurance per child. If. this was the last thing you ever did for them it would be something you never regret.
Recommended Life Insurance Coverage for your family:
This is the amount of Life Insurance we would recommend for your family to pay off any debt that you have, replace your income, leave money to your children, and pay for final expenses.
Would you like a Free Quote on Life Insurance for your family? answering the questions for a quote takes less than 2 minutes.
To start your Life Insurance Quote we just need to ask you a few medical and personal questions. Please fill out the information below for the first person you would like a quote on:
Name

First NameLast Name
What is your birthday?
What is your drivers license number?
What is your social security number?
What is your occupation and what is your employers name?
Approximate annual income?
How tall are you?
How much do you weigh?
Who is your primary care physician? (PCP)
What city and state is your PCP in?
Have you in the past five years, used Tobacco or Nicotine products in any form (e.g. cigarettes, pipes, cigars, snuff, chewing tobacco or nicotine delivery device such as gum or patch, etc.)?
If Yes: Please let us know the last time you used a tobacco or nicotine product, what types of products used, and how long you have used them.
Have you in the past five years, been admitted or advised to be admitted to any hospital or health care facility: or undergone or been advised to have surgery, biopsies, treatment or medical test?
If Yes: Where, what for, and what was the outcome?
Have you, in the past five years, been diagnosed by a member of the medical profession for any illness, disease, or injury?
If Yes: what was the diagnosis, when was the diagnosis, who was the doctor that diagnosed you, and if you are taking prescriptions for it, we need the name and dosage.
Have you, in the past five years, been prescribed any prescription medication by a member of the medical profession for any illness, disease, condition or injury?
If Yes: We need to know the name, dosage, and how often you take the prescription. What condition was the prescription written for, who was the prescribing doctor, how long you have been taking it, and when did you stop taking it or are you still taking it?
Have you, in the past five years, been disabled received disability income benefits, or been unable to work or perform any carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?
If Yes: When, why, and is it an ongoing issue?
Have you ever been treated for, drug or alcohol addiction?
If yes: When, where and what for?
Have you ever attempted suicide?
If Yes: When and did you receive treatment?
Have you, in the last 10 years, had your driver's license suspended, revoked, pled guilty to, or been convicted of reckless driving, or driving under the influence (DUI/DWI)?
If Yes: When, where and was the ticket for?
Have you, in the past 10 years, pled guilty to or been convicted of a felony or misdemeanor, or are such charges pending against you, or are currently on parole or probation?
If Yes: When, where, and what was the charge, conviction, if on parole or probation when does it end?
Have you had an application for life, accident, or health insurance or reinstatement of a policy, declined, postponed, cancelled or issued other than as applied for?
If Yes: when, what company, and what was the reason it was declined for?
Are you a member of the military, military reserve or National Guard (active or inactive) or do you have a written agreement to become a member at a future date?
If Yes: what branch, what is your enlistment date, what is your anticipated discharge date? have you been alerted or received orders for service outside the US?
Are you currently receiving, or within the next two years do you expect to receive, hazardous duty or incentive pay?
If Yes: what are your job duties, where will they be performed, and when will they be performed?
In the next two years, do you plan to work or reside outside the US?
If Yes: Where, when, how long and what is the reason?
Have you, in the past two years, flown as a student pilot, pilot or crew member (or do you plan to within the next two years)?
Have you, in the past two years, or do you plan to in the next two years, take part in hang gliding, para sailing, para kiting, parachuting, skydiving, ultralight, soaring, ballooning, bungee jumping, rock or mountain climbing, organized racing by automobile, motorcycle, powerboat or snowmobile, or underwater diving?
Within the past 90 days have you been unable to perform the normal duties of his/her occupation for 15 or more working days because of health reasons?
If Yes: When why and is it an ongoing issue?
Do you have another person you would like a quote on?
Relation?
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Should be Empty:

Family Financial Needs Questionnaire

To start your Life Insurance Quote we just need to ask you a few medical and personal questions. Please fill out the information below for the first person you would like a quote on: