GJ Insurance Group - Life Insurance Fact Finder

1

Date of Birth* This field is required.

Date

2

Height* This field is required.

3

Weight* This field is required.

4

Sex* This field is required.

5

Occupation* This field is required.

6

Relationship Status* This field is required.

7

Number & Ages of Children* This field is required.

8

Do you use tobacco or nicotine products?* This field is required.

YESNO

9

If so, what type and how often?

10

Do you take any prescription medications?* This field is required.

YESNO

11

If so, list all belowPrescription name, dosage & reason for taking

12

Do you currently have an income?* This field is required.

Yes

No

13

Your annual income ($)* This field is required.

14

# of years to cover income* This field is required.Recommend putting 3-7 years. It's the # of years your family will need to replace income or reduce expenses.

15

Do you currently have a mortgage?* This field is required.

Yes

No

16

Mortgage Balance ($)* This field is required.

How much is left on your home mortgage?

17

Do you have children that you expect to attend college?* This field is required.

Yes

No

18

Total cost of education ($)* This field is required.Recommend putting $72,000 for four-year in-state public university and $158,000 for private college

19

# of children* This field is required.

20

Current debt $* This field is required.Debts other than mortgage

Auto loans, credit cards, home equity line, etc.

21

Estimated final medical and funeral expenses $* This field is required.

Typically $10,000-$15,000

22

Available assets $* This field is required.You may or may not choose to subtract your assets from your life insurance need after a discussion with your Agent.

Savings, CDs, Other

23

Do you currently have any life insurance?* This field is required.

Yes

No

24

Other life insurance value $Include any individual policies. Don't include accidental death insurance.

25

Please upload any other life insurance documents or helpful statements below.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

26

Name* This field is required.

First Name

Last Name

27

Email * This field is required.

example@example.com

28

Mobile Phone* This field is required.

Please enter a valid phone number.

29

ZIP Code* This field is required.

30

Preferred Contact Method

31

I agree that GJ Insurance Group may contact me by phone, text, or email about my life insurance estimate.* This field is required.

I agree