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?

Is your spouse a smoker? (if applicable)

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*


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