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Life & Health Questionnaire

What Concerns You The Most?

 

There are a number of different areas to consider when planning for your future financial security. Most !inaneial experts recommend planning for your needs in the event of death or disability first. In any case, it is important 10 prioritize your needs and implement a plan of action to meet your financial goals.

 

Which areas are important to you?

Needs in the Event of Death - Examine the financial impact of a death, including immediate cash needs and continuing income needs.
College Funding - Examine the cost of college and alternative methods of funding.
Retirement - Examine how your current retirement planning compares to your objectives.
Disability Income - Examine the financial impact 01 a disability on your income.
Long-Term Care - Examine the devastating impact long-term care costs can have on your financial situation.
Health insurance - examine the devastating impact of media / bills can have on your financial situation
 

Personal Information

 
  Client A Client B
First Name : *
Middle Name :
Last Name :*
Date of Birth :*
MM/DD/YYYY (for example:05/20/2010) MM/DD/YYYY (for example:05/20/2010)
Are You Married ?
Yes
No
Street Address : *
City :* State :* Zip :*
Phone :*
(
)
 Email :*
 
  Client A Client B
Employer : *
Occupation :
Work Phone :*
(
)
(
)
 

Dependent Jnformation

Child's Name Date of Birth
 
I prefer to be contacted via :
Phone
Email
Mail

Provide Financial Information
Now
Later

Financial Information

Complele this seclioo il you also completed .he Needs in lhe Event 01 Oealh Of Relirement seclioo.

 
  Client A Client B
Annual Employment Income : *
( For other sources of income, enler the de/ails In the Other Sources of Income section below. )
Do you contribu te to Social Security?
Yes
No
Yes
No
 

Assets

Enter ailhar the totals IOf your assels in the shaded aroa or list the details 01 the indivk:lual accounts below. Include savings, checking, CDs, money market accounts, stocks, bonds, muluallunds, real OSIala (other than your residence). ole. Do not incluclo assets earmarked for education needs or retirement plans such as 401 (k)s and tRAs.

 
Assel Owner
Account Name
Amount
$
$
$
$
$
Monthly Savings
$
$
$
$
$
Rate of Return
%
%
%
%
%
 

Retirement Plans

Enter either lhe totals for your retirement plans including IRAs, 401 (k)s, variable annuities, etc., in the shaded area, Of list the details 01 the individual accounts below. List defined benefit pension plans in the Othor Sources of Income section below.

 
Account Owner
Account Name
Amount
$
$
$
$
$
Monthly Savings
$
$
$
$
$
Company Match
$
$
$
$
$
Rate of Return
$
$
$
$
$
 

Liabi lities

Enter your current li abilities.

 
Morlgage Balance     or
Monthly Rent
Other Liabilities
Amount
$
$
$
$
$
Monthly Payment
$
$
$
$
$
Final Payment Due
Interest Rate
$
$
$
$
$
 
 
Next >>

One Final Question

Are there any spocial ci rcumstances that st10uld be considored in analyzing your situation?

For Example, Children with special needs, dependent parents, etc.

 

Insurance Center, Inc.

 

4560 Via Royale #1
Fort Myers, FL 33919

Phone: 239-939-9991
Email: info@emailmyagents.com

 

Directions

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Testimonials

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About Us

Insurance Center, Inc. partners with reputable companies to offer protection for your Auto, Home, Health, Business, and Life Insurance. This means that you’re covered by a stable company through an agency whose dedication to service is strictly paramount. At Insurance Center, Inc our #1 job is to assist you in identifying your needs and problems while putting together a customized plan to address your specific concerns. A plan that's simple and easy to understand.

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Call Us Today !!
239-939-9991

 

4560 Via Royale #1
Fort Myers, FL 33919 Email: info@emailmyagents.com

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