Mortgage Protection Coverage Questionnaire

You’re in the Right Place

I’m Tori — an independent life insurance broker.This short questionnaire helps me understand your needs so I can explore protection options that make sense for you, whether you’re looking for mortgage protection or general life insurance.Your answers are confidential.
🔹 SECTION 1: Basic Information
Name*

First NameLast Name
Age*
State of Residence*
Licensed in GA, MI, OH, SC, VA, & TX
Email Address*
Phone Number*
Please enter a valid phone number.
🔹 SECTION 2: Mortgage & Coverage Needs
Do you currently have a mortgage?*

YesNo
What is your approximate mortgage balance?*

Under $150,000$150,000 - $300,000$300,000 - $500,000Over $500,000
How important is it that your family could stay in the home if something happened to you?*

Extremely importantSomewhat importantNot sure
Other Protection Goals: What would you like to focus on protecting instead?*

Income protectionFamily expensesFinal/Burial expensesExploring general life insurance options
🔹 SECTION 3: Timing & Preferences
What monthly range feels comfortable to start the conversation?*

As low as possibleAround $50 - $100Around $100 - $150Flexible /open to guidance
That makes sense — many people feel the same way.
My role is to review what’s realistic for your goals and show you the closest options, and then we decide together.
How soon would you like coverage in place?*

As soon as possibleWithin the next 30 daysJust exploring options
🔹 SECTION 4: GENERAL HEALTH SNAPSHOT
How would you describe your overall health?*

Very goodGoodFair
Have you had any major health events, such as surgeries or accidents, requiring a hospital stay within the past 10 years?*

YesNo
Do you currently have or have you ever been diagnosed with any of the following? (Check all that apply.)*

High Blood PressureHeart AttackStrokeCancerDiabetesHigh CholesterolNone of the aboveOther
🔹 SECTION 5: LIFESTYLE OVERVIEW
Do you currently use tobacco products?*

YesNo
Do you regularly participate in any activities that could be considered higher-risk?

YesNoNot sure
Is your driving record generally clean?*

YesNoPrefer to discuss
Other Considerations
Is there anyone else you’d like to consider protecting (such as a spouse or partner)?*

YesNoMaybe
Is there anything else you think would be helpful for me to know before we talk?
When is the best time of day to reach you by phone?*

Morning (8am–12pm)Afternoon (12pm–5pm)Evening (5pm–8pm)Anytime worksPrefer email instead
Questions?

Tori Green | Independent Life Insurance Advisor
NPN #234432
Licensed in GA, TX, OH, MI, VA & SC
📧 tori@torigreen.net

Your information is confidential and never shared.
Should be Empty:

You’re in the Right Place

🔹 SECTION 1: Basic Information

🔹 SECTION 2: Mortgage & Coverage Needs

🔹 SECTION 3: Timing & Preferences

🔹 SECTION 4: GENERAL HEALTH SNAPSHOT

🔹 SECTION 5: LIFESTYLE OVERVIEW

Other Considerations