Life Insurance Analysis - financial protection for your family. let US better understand your financial protection needs with a simple ANALYSIS. Please complete the form below Legal First & Last Name * First Name Last Name Gender at Birth * Female Male Date of Birth * MM DD YYYY Province * Where you currently reside. British Columbia Alberta Saskatchewan Manitoba New Brunswick Newfoundland & Labrador Nova Scotia Quebec Yukon Ontario Northwest Territories Price Edward Island Nunavut Do you smoke or vape? * Yes No Do you have a spouse/partner? If yes, please insert legal First & Last Name. First Name Last Name How many children do you have? * 0 1 2 3 4 5 Other If you have children, please list their date of birth(s) below: DD/MM/YYYY Your Household's Annual Gross Income * Let’s make sure your family will be able to enjoy the same lifestyle if you were to pass away. $ Do you currently hold a Life insurance policy? * We want to make sure you're properly insured—even if it’s not through us. Yes No If yes, what is the total coverage amount? * $ Do you actively hold a Mortgage? * Yes No What is your Mortgage balance? Please be as exact as possible. $ How much overall debt do you have? * $ How much do you have in savings and other monetary assets? * $ How much do you want to set aside for funeral expenses? * A desired amount. $ How many years after you pass do you wish to support your dependents? * How Healthy Are You? * Inactive Lightly Active Active Very Active What do you want your future to look like? * Your financial future, rather. I want to be able to access cash, if needed, to supplement my retirement savings and pension. I want to be able to access a portion of my death benefit if I become seriously ill or disabled. I want to ensure my debts are paid off should something happen to me. I would like to supplement my group insurance with my own coverage so I don't lose protection if I change jobs. Do you want coverage for life or for a certain time period? * The length of coverage desired. Lifetime Specific term What matters the most in your financial future? * Financial security to my loved ones with the option to accumulate cash value that I can use towards other expenses. Temporarily protecting my loved ones’ financial future by replacing my income if I pass away. Your Best Contact Phone Number * (###) ### #### Your Email Thank you for completing our protection analysis questionnaire! A highly qualified agent will be in touch with you shortly. We have multiple products or coverage values that are best suited to you, and your family.
