Clone of Life Insurance Needs Analysis

Name*

First NameLast Name

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

Obviously it would be a good idea for all of that to get paid off for your family if something were to happen to you right? Pause and wait for them to answer.

Income

The next thing on the list is replacing your income for your family. If something were to happen to you your family has two choices that they are faced with immediately, either make more money or live on less and they cant do that overnight. They need time to adjust and figure their finances out. So, the life experts at Farmers recommend that families have 10 years of income replacement. What do you make annually?

Annual Income*

Are you married?

YesNo

Spouse's Name

First NameLast Name

Spouse's Annual Income*

Annual Household Income

Roth IRA Disqualified

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. Also you can contribute as much as you want, and you can withdraw the money before age 59 1/2 with no early withdrawl penalty.

Jesse is an expert on this topic and can explain more about how it works, if you decide its something your interested in.

Final Expenses

We also build in $20,000 for everyone for funeral costs. Obviously, its important to pay for your own funeral. You wouldn't want that to be a burden for your family, so we build it in for everyone. No one wants to be a Go-Fund Me..

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 some money for each of your kids for college that would be something you would never regret. How many kids do you have?

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

No Coverage

Not a problem, that is why we do this with everyone. It is our job to help you with things like this.

To get started on a quote I just need to ask you a few questions. Who would you want to be your beneficiary?

Coverage at Work

That's fantastic, work policies are great because they are usually very inexpensive, however they are usually also very small and don't provide you with enough coverage. Plus, if you change jobs, quit, retire or whatever you cannot take your coverage with you, so we always recommend that our clients own a policy independently in addition to their policy from work.

To get started on a quote I just need to ask you a few questions. Who would you want to be your beneficiary?

Another Company

That's great, most people that I talk to have no coverage at all. But, it looks like the amount of coverage you have is not what your family needs currently. Did the agent do a needs analysis like this with you?

To get started on a quote I just need to ask you a few questions. Who would you want to be your beneficiary?

Ok great, this should be pretty easy for you then. Who would you want to be your beneficiary?

First NameLast Name

Beneficiary

If the customer refuses to continue

I understand the timing for this may not be right at the moment. I will send you an email with this info and follow up with you in a few months to see if you have any quetiosns.

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?*

How tall are you?*

How much do you weigh?*

Who is your primary care physician? *

What city and state is your primary care physician located 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.)?*

YesNo

If yes: please let us now when the last time you used a tobacco or nicotine product was, what types of products you use, and how long you have used them?

Do you use Marijuana products recreationally? If so it's ok because it's legal we just have to ask a few additional questions for underwriting.*

YesNo

Are you attending or have you attended any type of self-help organization for drug usage?

NoYes

Have you ever been treated by or consulted a member of the medical profession for abuse of prescription or other drugs?

NoYes

Have you ever lost time from work due to drug usage?

NoYes

Have you ever been convicted of and drug related offences, or had your drivers license suspended or revoked for drug related offences?

NoYes

If yes please give details:

Make sure to fill out the supplemental Drug Usage Form and have the customer sign it as it will be required for underwriting. You can use docusign if needed to get it signed.

Link to form: Drug Usage Form 51-1573

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, in the past five years, been disabled, received disability income benefits, or been unable to work or perform and carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?*

YesNo

If yes: when, why, and is it an ongoing issue?

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?

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?*

YesNo

If yes: what branch, what is your enlistment date, what is your anticipated discharge date? Have you been alerted or received orders for duty outside the US?

Are you currently receiving, or within the next two years do you expect to receive, hazardous duty or incentive pay?*

YesNo

If yes: what are your job duties, where will they be performed, when will they be performed?

Within the next two years, do you plan to work or reside outside the US?*

YesNo

If yes: when, where, how long, and what is the reason?

Have you, in the past two years, flown as a student pilot, pilot or crewmember (or do you plan to within the next two years)?*

YesNo

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?*

YesNo

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?*

YesNo

If yes: when, why, and is it an ongoing issue?

Do you have another person that you would like a quote on?*

YesNo

What is your name?*

First NameLast Name

What is your birthday?*

What is your drivers license number?*

What is your social security number?*

What do you do for work, and what is your employers name?*

What is your approximate annual income?*

How tall are you?*

How much do you weigh?*

Who is your primary care physician? *

What city and state is your primary care physician located 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.)?*

YesNo

If yes: please let us now when the last time you used a tobacco or nicotine product was, what types of products you use, and how long you have used them?

Do you use Marijuana products recreationally? If so it's ok because it's legal we just have to ask a few additional questions for underwriting.*

YesNo

Are you attending or have you attended any type of self-help organization for drug usage?

NoYes

Have you ever been treated by or consulted a member of the medical profession for abuse of prescription or other drugs?

NoYes

Have you ever lost time from work due to drug usage?

NoYes

Have you ever been convicted of and drug related offences, or had your drivers license suspended or revoked for drug related offences?

NoYes

If yes please give details:

Make sure to fill out the supplemental Drug Usage Form and have the customer sign it as it will be required for underwriting. You can use docusign if needed to get it signed.

Link to form: Drug Usage Form 51-1573

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, in the past five years, been disabled, received disability income benefits, or been unable to work or perform and carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?*

YesNo

If yes: when, why, and is it an ongoing issue?

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?

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?*

YesNo

If yes: what branch, what is your enlistment date, what is your anticipated discharge date? Have you been alerted or received orders for duty outside the US?

Are you currently receiving, or within the next two years do you expect to receive, hazardous duty or incentive pay?*

YesNo

If yes: what are your job duties, where will they be performed, when will they be performed?

Within the next two years, do you plan to work or reside outside the US?*

YesNo

If yes: when, where, how long, and what is the reason?

Have you, in the past two years, flown as a student pilot, pilot or crewmember (or do you plan to within the next two years)?*

YesNo

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?*

YesNo

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?*

YesNo

If yes: when, why, and is it an ongoing issue?

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Application for Life Insurance

Please answer the personal and medical questions below for the second person you would like a quote on: