Disability/Life Insurance Survey

1. Please provide the following information: *This question is required.

Date of Birth (ex: 01/01/57) *This question is required.

Weight (ex: 135 lbs) *This question is required.

Height (ex: 5 ft. 5 inches) *This question is required.

3. When was last use? (Ex: 06/2014) *This question is required.

3. Please provide details on any medical condition, history, medication, etc. We can expand on this if necessary when we speak but if there are any medical conditions that you are or have been treated for it would be helpful to learn about them so we can properly factor them into the quotes. *This question is required.

4. Any family history of a parent/sibling who was diagnosed with or died from cancer or heart disease prior to age 65? *This question is required.

5. Age of Diagnosis (Ex: 63) *This question is required.

5. Age of death (if applicable): *This question is required.

5. What is your gross annual income before taxes? (Ex: $45,000) *This question is required.

6. What is your current occupation? *This question is required.

7. Given your gross annual income, please choose the answer that best applies to your situation: *This question is required.

8. What annual income amount (before taxes) should be replaced? (Ex: $45,000) *This question is required.

8. Do you have a mortgage balance outstanding? *This question is required.

9. What is the total current principal balance of any outstanding mortgage(s)? *This question is required.

9. Do your current savings/investments exceed $50,000? (Please consider all retirement and savings accounts) *This question is required.

10. What is the total value of your retirement accounts, non-retirement investments and savings? *This question is required.

10. Do you have any existing life insurance, either through group life benefits from employer or personal insurance policy(ies)? *This question is required.

11. Please provide as much information as possible about the insurer name, amount, type/duration, and cost of your existing coverage *This question is required.

11. Do you have any existing disability income protection coverage through your employer, or through personal insurance? *This question is required.

12. Please provide details about your coverage (employee benefit plan or personal policy, amount of income replaced and duration of income replacement): *This question is required.

12. Do you currently have Long Term Care Insurance? *This question is required.

13. Please provide the name of insurer & how long you have had coverage: *This question is required.

13. Are you at a point where you are aware of and wish to take future planning for Long Term Care expenses into consideration?

There are a number of ways to do this (beyond "traditional" LTC insurance) if you are in a position to want to discuss. *This question is required.

13. Do you have a spouse? *This question is required.

14. Does your spouse earn an income from employment? *This question is required.

14. What is your spouse's current income: (Ex: $45,000) *This question is required.

14. Do you have any dependents/children? *This question is required.

15. How old are your dependents/children *This question is required.

15. Do you have a pre-determined knowledge or concept of the amount and duration of coverage that you want/need to see quoted?

If not, we are happy to run a brief needs analysis based on the information collected above. *This question is required.

16. Please provide the amount and duration of coverage you have in mind. Describe any other information you would like included in your quote: *This question is required.

16. Please fill out the following Contact Information: *This question is required.

First Name *This question is required.

Last Name *This question is required.

Street Address *This question is required.

City *This question is required.

State *This question is required.

Zip *This question is required.

Email Address *This question is required. This question requires a valid email address.

Best Phone Number to reach you (Ex: 703-123-4567) *This question is required.