STORY Needs Analysis Form.

1
Personal Details.This includes; Name, D.O.B and Gender
Huge
Large
Normal
Small
Ok
Ok
2
EmailPlease enter individual email address' for all those to be considered in this assessment.
example@example.com
3
AddressMain personal residence.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Do You Have Children or Dependents?
YESNO
5
Child InformationPlease list Name, Age and Gender if applicable. Leave blank if previously listed.
Huge
Large
Normal
Small
Ok
Ok
6
What Is The Main Reason For Seeking Financial Advice?We offer our clients a range of solutions to fit their unique needs and goals.
Increased debt
Peace of mind
Starting a family
Financial security
Protect loved ones
Protect assets
Protect income/lifestyle
Not sure yet!
Grow wealth
7
In Relation To Life & Health Insurance, What Is Most Important To You?This could be a range of options, or something specific. Please tick any of the below that is relevant to you.
Private hospital treatment
Ensuring debt doesn't pass onto loved ones if you pass away
The ability to cover bills/mortgage if you were unable to work for an extended period of time
Maintain your current lifestyle if you suffered a serious illness or injury
Health cover for the children
It's not something I have considered yet
8
Select One Option That Best Describes You.We want to ensure our recommendations fit with your ideas and budget.
We want a comprehensive insurance package that offers solutions for a variety of events.
We want a good amount of cover that offers solutions for major events.
We are budget conscious, and would like a solution that is minimal but effective.
We are happy to self-insure for most events and are looking for a very specific solution.
Not sure yet!
9
Have You Ever Suffered A Serious Illness Or Injury?Please give a brief description of the event. Please include details for all lives to be insured.
Huge
Large
Normal
Small
Ok
Ok
10
Are You Currently Taking Medication or Under Medical Observation?For example: If you are planning on having a blood test, x-ray or surgery as recommended by a medical professional.
Huge
Large
Normal
Small
Ok
Ok
11
Are You A Smoker?This applies if you have smoked regularly (including e-cigarettes) in the last 12 months.
12
What Is Your Occupation?Job Title & Industry. Please include details for all lives to be insured.
13
Does Your Occupation Involve Any Manual Tasks or Duties?To better understand any risk in your occupation, please outline the duties that would not be considered desk-based. Please include details for all lives to be insured
Huge
Large
Normal
Small
Ok
Ok
14
What Is Your Annual Income?This will allow us to determine the level of cover you could consider. Please include details for all lives to be insured.
15
What Is/Will Be Your Debt Level (Mortgage Total - if applicable).This will allow us to determine how much cover you might need to protect your loved ones/assets if something happened to you.
16
What Are Your Monthly Mortgage or Rental payments?
17
Do You Have Any Other Significant Debts?This will allow us to ensure all debts are considered in your insurance plan.
Huge
Large
Normal
Small
Ok
Ok
18
Do you have KiwiSaver?We can provide expert advice for your KiwiSaver plan. Please provide details below if currently enrolled.
Huge
Large
Normal
Small
Ok
Ok
19
Do You Have Any Other Significant Savings or Investments? This will allow us to ensure any ability to self-insure is taken into consideration.
Huge
Large
Normal
Small
Ok
Ok
20
Do You Have Any Other Properties?Please list type and value, if known.
Huge
Large
Normal
Small
Ok
Ok
21
Does Your Work Offer Any Insurance Benefits? Life or Health insurance benefits included in your employment package.
YESNO
22
Do You Have Any Existing Life or Health Insurance Cover?Please include which company, the type of cover and the total sum insured.
Huge
Large
Normal
Small
Ok
Ok
23
Please Let Us Know Any Other Relevant Details About You.
Huge
Large
Normal
Small
Ok
Ok
24
Please read the below and sign as confirmation of acceptance.I/We authorise Story Financial Group Limited, and related third party service providers to collect, hold, use and disclose our personal information so that Story Financial Group Limited can provide services and advice to us in relation to the above. I/we acknowledge and understand that the service being provided is limited to those areas outlined in the Scope of Service and that if I do not provide the correct information requested by my adviser in relation to that scope, the advice I receive may not be suitable or meet my financial needs and/or goals. I/we acknowledge and understand that full and accurate financial and medical disclosure is required when applying for Financial Services and failure to do so may affect cover at claim time. I/We acknowledge receipt of the Adviser Disclosure Statement for Lisa Goss providing advice on behalf of Story Financial Group Limited.
Powered by Jotform SignClear
Should be Empty: