Life Insurance Form All fields that have the * symbol are required. General Information Client Name Spouse Name (if applicable) Telephone Email Are you a smoker? YesNo Is your spouse a smoker? (if applicable) YesNo What is your current total life insurance value? Self: Spouse (if applicable): How much will be needed at death to meet your immediate obligations? Funeral Expenses Self: Spouse (if applicable): Loans (e.g. Car, School) Self: Spouse (if applicable): Credit Cards/Lines of Credit Self: Spouse (if applicable): Mortgage Debt? Self: Spouse (if applicable): Education Funding Self: Spouse (if applicable): Emergencies Self: Spouse (if applicable): How much income is needed to sustain your survivors? Annual Income Needed After Tax? Self: Spouse (if applicable): For how many years? Self: Spouse (if applicable): Current Financial Assets to Assist in Loss of Income What is your home value? What is the value of your RRSP? Self: Spouse (if applicable): What is the value of your pension? Self: Spouse (if applicable): What is the value of any other investments? Self: Spouse (if applicable): Advisor Name* Select an AdvisorMike TaltyChad ViminitzJon CraigDoug RocheCam D. Trahan I have read and agree to the terms in the privacy policy. Personalized Form ListLife Insurance Blueprint Form Personal Blueprint Form Client Risk Profile Form Client Profile Form Business Blueprint Form