Complete this section only if you currently have insurance

Why did you buy your existing plan(s)?

What type of policy do you currently have?

What is the coverage amount?

Do you know your current monthly premiums?

Do your children have policies? If so, how much?

Health Questions:

Do you use tobacco in any form?

How is your health?

What is your height and weight?

Additional Coverage

Do you have a current will?

Do you own any Critical or Disability insurance?

Yes

No

Just Critical

Just Disability

Insurance Goals

About how much coverage do you think you need?

Who do you want to your beneficiary?

If you were to pass away would you want your…

How much to pay off your Debt?
How much to pay off your Morgage?
How much to pay off your kids education
How much for Funeral & Final Expenses
How many yrs would you need Income Replaced

What is your annual income?

How much would you be willing to budget on a monthly basis towards your coverage?

Who are the 5 people who could benefit from this information?

Name and Phone Number

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