How much Life Insurance do you need?

Name*

First NameLast Name

DEBT

Calculate the amount of debt that you currently have, so that you can leave your family debt free.

How much would it take to pay off your mortgage?*

How much would it take to pay off any other debt you may have like, auto loans, credit cards, ect.*

INCOME

If something were to happen to you tomorrow, your family would immediately be faced with two choices: make more money or live on less, and they cant do that overnight. They need time to adjust. Life experts recommend that families have 10 years of income replacement.

Annual Income*

Are you married?

YesNo

Spouse's Name

First NameLast Name

Spouse's Annual Income*

Annual Household Income

Roth IRA Disqualification

Did you know that because of your high income, you do not qualify for a Roth IRA, which allows you to have tax free money in retirement?

Most people are unaware that Life Insurance policies are another way to get the same tax free retirement savings, but with no income restrictions. It also allows you to contribute as much as you want, and withdraw your money before age 59 1/2 with no early withdrawal penalty.

Our Agency is an expert on this topic and can explain more about how it works, if you decide it is something you are interested in.

FUNERAL

We also build in $20,000 for everyone for funeral costs. Obviously, its important to pay for your own funeral and remove that burden from your family.

Funeral Cost 1

Funeral Cost 2

EDUCATION

The last thing on the list is educational funding for your children. We recommend adding $100,000 for each child. If the last thing you ever did for them was leave money for each of your kids education expenses, that would be something you would never regret.

Number of Children*

The recommended amount of Life Insurance for you on this needs analysis is:

How much coverage do you currently have and what company is it with?

No coverageCoverage at workHas a policy with another company

Not a problem, let us help!

To obtain a quote for you and/or your spouse, answer a few more questions below, and we will be able to send you the most suitable products and rates for you and your family!

That's fantastic, work policies are a great supplement to individual Life Insurance.

To obtain a quote for individual products that stay active regardless of your employment status, answer a few more questions.

We will send you the most suitable products and rates for you and your family!

That's great, most people that we speak with have no coverage at all. But, it looks like the amount of coverage you have is not what your family needs currently. That's why it is important to assess your needs as time passes and your family changes.

To get started on a quote, we just need to ask you a few questions. We will then email you the rates and call you to go through the available options.

What is your birthday?*

What is your occupation and what is your employers name?*

How tall are you?*

How much do you weigh?*

Have you, in the past five years, used Tobacco, Nicotine products or Marijuana in any form (e.g. cigarettes, pipes, cigars, snuff, chewing tobacco or nicotine delivery device such as gum or patch, etc.)?*

YesNo

If yes: please let us now when the last time you used them, what types of products you use, 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?*

YesNo

If yes: where, what for, and what was the result or outcome?

Have you, in the past five years, been diagnosed by a member of the medicalprofession for any illness, disease, or injury?*

YesNo

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?*

YesNo

If yes: we need to know the name, dosage, and how often you take the prescription. What condition was the prescription written for, who the prescribing doctor was, how long you have been taking it, and when did you stop taking it or are you still taking it?

Have you ever been treated for, drug or alcohol addition?*

YesNo

If yes: when, where, and what for?

Have you ever attempted suicide?*

YesNo

If yes: when and did you receive treatment?

Have you, in the past 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)?*

YesNo

If yes: when, where, and what was the ticket written 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 you currently on parole or probation?*

YesNo

If yes: when, where, and what was the charge, what was the 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?*

YesNo

If yes: when, what company, and why was it declined?

Ages of your parents, and if deceased, age they passed, and from what reason?

Ages of your siblings, and if deceased, age they passed and from what reason?

Primary Doctor or last doctor seen, date of last visit, and reason?

Primary Beneficiaries, their phone numbers, and % ?

Contingent Beneficiaries, their phone number and %? (If one or all of primary beneficiaries are deceased, their share passes to the contingent beneficiaries.)

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Driver's License#, expiration date, Social Security, and Routing and Account number for the bank you want to use to pay your premiums. If you are not comfortable submitting, please enter NA and we will call you to obtain.