Life Insurance Needs Analysis
Name
*
First Name
Last Name
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.
*
Annual Income
*
Are you married?
Yes
No
Spouse's Name
First Name
Last Name
Spouse's Annual Income
*
Annual Household Income
Final Expenses
We recommend $20,000Â
Funeral Cost 1
Funeral Cost 2
Education
Â
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 coverage
Coverage at work
Has a policy with another company
Who would you want to be your beneficiary?
First Name
Last Name
Beneficiary
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.)?
*
Yes
No
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.
*
Yes
No
Are you attending or have you attended any type of self-help organization for drug usage?
No
Yes
Have you ever been treated by or consulted a member of the medical profession for abuse of prescription or other drugs?
No
Yes
Have you ever lost time from work due to drug usage?
No
Yes
Have you ever been convicted of and drug related offences, or had your drivers license suspended or revoked for drug related offences?
No
Yes
If yes please give details:
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
If yes: when, why, and is it an ongoing issue?
Have you ever been treated for, drug or alcohol addition?
*
Yes
No
If yes: when, where, and what for?
Have you ever attempted suicide?
*
Yes
No
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)?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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)?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
If yes: when, why, and is it an ongoing issue?
Do you have another person that you would like a quote on?
*
Yes
No
Please answer the personal and medical questions below for the second person you would like a quote on:
What is your name?
*
First Name
Last 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.)?
*
Yes
No
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.
*
Yes
No
Are you attending or have you attended any type of self-help organization for drug usage?
No
Yes
Have you ever been treated by or consulted a member of the medical profession for abuse of prescription or other drugs?
No
Yes
Have you ever lost time from work due to drug usage?
No
Yes
Have you ever been convicted of and drug related offences, or had your drivers license suspended or revoked for drug related offences?
No
Yes
If yes please give details:
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
If yes: when, why, and is it an ongoing issue?
Have you ever been treated for, drug or alcohol addition?
*
Yes
No
If yes: when, where, and what for?
Have you ever attempted suicide?
*
Yes
No
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)?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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)?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
If yes: when, why, and is it an ongoing issue?
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: