Town Financial Life Insurance Questionnaire

1

Insurance TypePlease indicate the type(s) of insurance that you are interested in.

Life

Disability

Critical Illnesss

Health & Dental

Mortgage (covering mortgage amount only)

2

Applicant Name* This field is required.Name of Applicant

First Name

Last Name

3

Will there be a Co-Applicant?* This field is required.Please indicate if there will be another party on the application.

YESNO

4

Co-Applicant NameName of Co-Applicant (Optional)

First Name

Last Name

5

Email Address* This field is required.Please enter your email address.

example@example.com

6

Phone Number* This field is required.Please enter your phone number.

Area Code

Phone Number

7

Date of Birth* This field is required.Please enter your date of birth.

Example: January 1 1980

8

Are you a smoker?* This field is required.Please indicate if you have consumed nicotine (in any form) within the last 12 months.

YESNO

9

Martial Status* This field is required.Please indicate the best description of your marital status.

Single

Common Law

Married

Separated/Divorced

Widowed

10

Date of Birth* This field is required.Please enter the date of birth for the Co-Applicant

Example: January 1 1980

11

Is the Co-Applicant a Smoker?* This field is required.Please indicate if the Co-Applicant has consumed nicotine (in any form) within the last 12 months.

YESNO

12

Current Mortgage AmountWhat is the approximate amount currently owing on your mortgage?

If you do not own a home type in RENT

13

Other Debts OwingWhat is the approximate amount of your other debts outstanding? (ex: credit cards, student loans, car loans, etc.)

14

Final ExpensesPlease indicate an amount that you estimate your final expenses to be. *The typical amount of a funeral in Canada today is between $5,000-$10,000. Final expenses can also include income taxes, executor fees, probate fees, etc. For an accurate calculation of this amount, an accountant should be consulted. For estimation purposes, we recommend an minimum of $50,000.

15

Income Replacement* This field is required.Would there be a need for any of your income (or the co-applicants income) to be replaced, in the event of your (or his/her) death? *In the event of a death, this would ensure that the survivors are able to maintain their current lifestyle and standard of living (covering things like utility bills,living expenses, extra childcare, cover monthly spousal/child support payments)

16

Annual Income Please indicate the amount of the current annual income to be replaced.

17

Percentage of Annual Income NeededWhat percentage of the income do you estimate the beneficiaries would need?

Between 40-70% is recommended

18

Time Period of Annual Income NeededWhat length of time do you estimate the beneficiaries would require the percentage of the income needed? *Example: Length of time your beneficiary would like to be off work or length of time children would require daycare, until retirement, etc.

19

Emergency Fund* This field is required.Would you like any emergency funds set aside for your loved one(s)? (To cover any unexpected costs that they may face in the future).

YESNO

20

Emergency Fund AmountPlease indicate the amount desired.

21

Education Fund* This field is required.Would you like an education fund set aside for your children in the event of your death?

YESNO

22

Education Fund AmountPlease indicate the amount desired. *Example: Annual education amount x number of years x number of children

23

Home to Be Sold?Would you want your home to be sold in the event of your death? Please select "No" if house will be left in the name of a beneficiary. *Please note that if you would like your home to be sold in the event of your death, there may be other costs associated with the sale of your home (other than your mortgage) that you may want to consider. (Example: market value, realtor fees, utilities, etc.)

24

Assets to Be SoldDo you have any assets of value that would be sold upon your death?

Example: jewelry, art collections, classic cars, etc.

25

Value of Assets to be soldPlease indicate the estimated value of any assets that would be sold upon your death.

26

Estate FundsDo you have any Registered (RRSPS, TFSAs, etc.) or Non-Registered (Mutual Funds, Stocks, etc.) that would be used toward final expenses or your beneficiary in the event of your death?

27

Estate Fund AmountPlease indicate that estimated amount that would be transferred to your loved one(s) or used towards final expenses, in the event of your death.

28

Current Life InsuranceDo you have any other current life insurance policies in place?

Please exclude any credit card insurances

29

Is Your Current Life Insurance Through Your Employment?

YESNO

30

Amount of Employment InsurancePlease indicate the amount of your current work insurance.

Please note typical employment policies cover one to two times your annual salary amount

31

Is Your Current Insurance With A Life Insurance Provider?Please indicate if you insurance is with a life insurance provider (outside of your employment coverage).

YESNO

32

Amount of Life InsurancePlease indicate the amount of your current life insurance.

33

Current Insurance ProviderPlease provide the name of your current insurance provider

34

Are you hoping to replace this insurance?Please indicate if you are looking to replace the insurance that you current have in place.

YESNO

35

History of HealthPlease provide an explanation below of any significant health issues that you (or the co-applicant) may current have or have had in the past.

36

Please understand that the values illustrated in this questionnaire are based on financial information that you have provided and your understanding of your future needs in the event of your death. The illustrated insurance coverage that is suggested, as a result of this form, is subject to medical and financial underwriting.

Your insurance coverage need must be reviewed on a regular basis to ensure that your financial goals and objectives continue to be met. The insurance value calculated as a result of this form is a suggestion of your insurance need and may not reflect the final amount that you decide to apply for. This questionnaire should be used as a guide to your insurance need amount based on the analysis of your needs in the event of your death.

37

Additional CommentsPlease include any additional comments that you may have below.

38

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