Quick Quote/Client Needs Analysis
Thank you for choosing Wishing Wealth Financial! This quick questionnaire helps me understand what you're looking for so I can prepare the right options for our conversation.
Name
*
First Name
Last Name
Phone Number & Email
*
555-555-555, example@example.com
Date of Birth (MM/DD/YYYY)
*
What is your gender
*
Male
Female
What products would you like to review or advice on?
*
Income Protection
Life Insurance
Critical Illness Protection
Short Term or Long Term Disability
Mortgage Protection
Short Term Disability or Long Term Disability
Hospital Indemnity
Retirement & Financial Strategies
Debt Elimination
I'm not sure. I need guidance.
Who needs a quick quote?
*
Me
My spouse/significant other
My child/children/dependents
My grandchild(ren)
My parents
Other
What do you want your coverage to accomplish?
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Pay my family's mortgage/home and other debts
Cover final expenses (funeral, burial, homegoing celebration)
Have living benefits
Cover my children's and/or grandchildren's future college or business expenses
Pay me directly if I become ill, injured, or disabled and cannot work
Supplement retirement income
I need help deciding
FOR THOSE WITH life insurance: list their name, date of birth, amount of coverage, the monthly amount for the coverage, and the company it is with. Type n/a if applies
*
FOR THOSE WITHOUT life insurance: list their name, date of birth, state born in, smoking status (if quit smoking, when?, and if do some smoke, what?) height, and weight. Type n/a if applies.
*
Do you have an emergency savings account?
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Yes
No
I need help with this
Do you have at least 2 retirement accounts?
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Yes
No
I need help with this.
Do you have any health conditions related to heart, kidney, or cancer?
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Yes
No
Are you currently prescribed any medication?
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Yes
No
If yes, please list them in the next section
Other
Please list current medications and what condition it's for. Type n/a if applies.
blank
*
Have you been denied for life insurance in the past 5 years?
*
Yes
No
Approximately how much debt do you have? (Approximately how much total debt would need to be addressed if something happened to you?)
*
$0
Under $25,000
$25,000-50,000
$50,000-100,000
over $100,000
I understand that submitting this form does not constitute an application for insurance or guarantee coverage. I authorize Wishing Wealth Financial to contact me regarding my request.
Submit
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