Needs Analysis Form

Use this form to convey your general financial situation and responsibilities. The form asks general, non-specific questions so an informed plan or plans of insurance coverage can be presented. The Quick Quote form should also be submitted along with this form.

All information is strictly confidential and used only to quote insurance.


Your Name (required)

Your Email (required)

Your best phone#

What products are you interested in?
 Life Insurance Final Expense Life Retirement Income Long Term Care Disability/Critical Illness Annuities

What is your birth date?

What is your expected average income the next few years?

What is your estimated retirement date?

How many people are at least partially dependent on your income?

Is there a spouse or partner dependent on your income?

 Yes No

What is their earning power in relation to you?
 less than 50% 50-75% 75-100% Over 100%

How much outstanding debt might you have at an unexpected passing? (Include burial costs, consumer debts, outstanding medical bills, mortgages, etc.)

How much liquid assets would be available to your dependents? (Do not include illiquid assets like primary residence or business equity)

How important is it to leave a financial legacy to family, close friends, church or charities?
 Not very Somewhat Fairly important Very important

What are your primary financial concerns going forward? (Check all that apply)
 Dependant security Retirement income Long Term Care Legacy to heirs Outliving assets Senior health costs

What other comments do you want to add?