Client Needs Analysis Form
Let's make sure you and your family are protected.
About You
We just need some details to get started.
Full Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Weight:
*
Height:
*
Example: 6'1
Marital Status:
*
Single
Married
Widowed
Separated
Divorced
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County:
*
Email:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Best Time to reach you:
*
Example 5 PM
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Work & Income
Tell us about what you do and what you bring in each month
What's your job title or what kind of work do you do?
*
Years in Current Role:
*
Work Status:
*
Full-Time
Part-Time
Self-Employed
Retired
Unemployed
How much do you bring in each month (after taxes):
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Monthly Expenses
Knowing your monthly bills helps us protect what matters.
Mortgage or Rent:
*
Car Payments:
*
Utilities:
*
Groceries & Essentials:
*
Health/Medical Expenses:
*
Credit Cards/Loans:
*
Student Loans:
*
Insurance Premiums:
*
Other
*Specify other:
Total Monthly Expenses:
*
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Insurance You Already Have
Just check what you currently have. If you know more details, list them.
Life Insurance:
Do you currently have this?
*
Yes
No
Company/Monthly Cost/Amount
Disability Insurance:
Income Protection
Do you currently have this?
*
Yes
No
Company/Monthly Cost/Amount
Health Insurance:
Do you currently have this?
*
Yes
No
Company/Monthly Cost/Amount
Medicare or Supplement:
Do you currently have this?
*
Yes
No
Company/Monthly Cost/Amount
Dental/Vision:
Do you currently have this?
*
Yes
No
Company/Monthly Cost/Amount
Final Expense
Burial Insurance
Do you currently have this?
*
Yes
No
Company/Monthly Cost/Amount
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What Matters Most to You?
Pick what feels most important right now. You can check more than one.
Check everything that's important to you in your plan.
*
Replacing my income if I can't work
Helping my family financially if something happens to me
Paying off my house or covering rent
Leaving money for my kids or loved ones
Covering funeral/final expenses
Building savings for emergencies
Saving for retirement
I'm not sure-I want to understand my options
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Family & Dependents
Tell us about anyone who counts on you financially.
Spouse/Partner Name:
First Name
Last Name
Children or Dependents (names/ages):
If you couldn't work or were no longer here, how much would your family need each month to keep going?
*
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Debts & Loans
List anything you owe that you or your family would still need to pay.
Type of Asset:
Estimated Value:
Who Owns It?
You
Spouse
Both
Does It Earn Income?
Yes
No
Balance Owed:
Type of Asset:
Estimated Value:
Who Owns It?:
You
Spouse
Both
Does It Earn Income?:
Yes
No
Balance Owed:
Type of Asset:
Estimated Value:
Who Owns It?:
You
Spouse
Both
Does It Earn Income?:
Yes
No
Balance Owed:
Type of Asset:
Estimated Value:
Who Owns It?:
You
Spouse
Both
Does It Earn Income?:
Yes
No
Balance Owed:
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Savings & Retirement
Check anything you have set aside for the future.
Emergency Savings:
Do you have this?
*
Yes
No
Current Value:
401(k), 403(b), or TSP:
Do you have this?
*
Yes
No
Current Value:
IRA (Traditional or Roth):
Do you have this?
*
Yes
No
Current Value:
Investment Account:
Do you have this?
*
Yes
No
Current Value:
Cash Value Life Insurance:
Do you have this?
*
Yes
No
Current Value:
Other:
Specify Other:
Current Value:
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Health & Lifestyle
These questions help determine what coverage options are available.
Have you used tobacco or nicotine in the last 12 months?
*
Yes
No
Any major health conditions? (heart issues, cancer, diabetes, etc.)
*
Yes
No
If yes, please list:
Do you currently take any medications?
*
Yes
No
If yes, which ones? (Name, Dosage, Reason):
*
Medications taken in past 10 years but not currently prescribed:
*
Have you ever been denied insurance?
*
Yes
No
Have you ever had a DUI or serious driving offense?
*
Yes
No
If yes, when?
Are you currently pregnant?
*
Yes
No
Any physical or mental health challenges that affect work or daily life?
*
Yes
No
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Business Owners (Optional)
Fill this out only if you own a business.
Business Name:
Type of Business:
Sole Proprietor
LLC
S Corp
C Corp
Partnership
Ownership %:
Do you have partners or key employees?
Yes
No
Do you have a backup or buy-sell plan in place?
Yes
No
Would you like info about business protection options?
Business income protection
Key employee coverage
Not sure, but I want to protect my business
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Final Steps
Notes (Optional)
If there's anything else you'd like to share, questions you have, or additional information that may help us serve you better, please write it here:
Authorization & Acknowledgment
*
I confirm that the information provided here is true and complete to the best of my knowledge. I understand this form is for planning purposes only, and I’m open to being contacted to discuss options that fit my situation. There is no obligation.
By signing below, I give permission for a licensed representative to contact me regarding the information I’ve shared.
Signature
*
Today's Date
*
-
Month
-
Day
Year
Submit
Submit
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