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*


    I have read and agree to the terms in the privacy policy.