Life Insurance Questionnaire

1

1. How much would you like to set aside for funeral and final expenses?* This field is required.(Category: Funeral & Final Expenses)

$10,000

$25,000

$50,000

Other

2

Funeral Value

3

2. What is your current outstanding mortgage balance?* This field is required.(Category: Mortgage Balance)

None

Less than $250,000

$250,000 – $500,000

Other

4

Mortgage Value

5

3. What is the total amount of debts you currently have (not including your mortgage)?* This field is required.(Category: Other Debts)

None

Less than $250,000

$250,000 – $500,000

Other

6

Other Debt Amount

7

4. Would you like to set aside money for a child’s education?* This field is required.(Category: Educational Support for Dependent)

None or not applicable

$50,000

$100,000

Other

8

Education Amount

9

5. What is your annual income?(Category: Household Income Replacement)

10

5.1. If you were to pass away, would your family need ongoing annual financial support?* This field is required.(Category: Household Income Replacement)

None

50% of my current annual income

25% of my current annual income

10% of my current annual income

11

Percentage income

12

6. How many years would your family need ongoing annual financial support?* This field is required.(Category: Household Income Replacement)

5 years

10 years

15 years

Other

13

PMT

14

N Years

15

PV Income Replacement

16

7. Would you like to set aside an emergency fund for your family or dependents?(Category: Emergency Fund)

None

$50,000

$100,000

Other

17

Emergency Amount

18

8. Do you have any other estate planning goals? (Charitable donation, support aging parents, leave a legacy)* This field is required.If Yes, specify how much in "Other" field

None

Other

19

Additional Amount

20

9. Do you have cash savings or existing life insurance coverage in place to help offset your needs. If so, how much?* This field is required.(Category: Existing Savings)

None

Less than $250,000

$250,000–$500,000

Other

21

Other Resources Amount Total

22

10. What do you hope life insurance will help you accomplish?

Pay off debts so nothing is left behind

Protect loved ones from financial hardship

Create a legacy / gift for future generations

Other

23

Your life insurance need:Your estimated life insurance need is shown below. This calculation is based on the information you provided. To confirm your exact insurance needs and receive complimentary, no-obligation quotes, please contact us to speak with one of our life insurance broker specialists.

24

Would you like to receive a personalized quote and schedule a no-obligation call with one of our specialists?* This field is required.

Yes

No

25

Contact Information* This field is required.

First Name

Last Name

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