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Part 1 - Your Family's Personal
Information |
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Members of Household |
Birthday |
Age |
Sex |
Occupation |
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1 |
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2 |
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3 |
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4 |
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5 |
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6 |
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7 |
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8 |
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Wedding Anniversary Date |
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Home Street Address
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City |
State |
Zip |
Home Phone
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Business Address
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City |
State |
Zip |
Business Phone
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Other Business Address: working spouse
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Business Phone
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Cell Phone
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Cell Phone
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E-Mail |
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E-Mail |
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Part 2 - Your Family's Current Auto
Insurance |
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Current Insurance Company & Effective Start/End date of Policy |
Make of Vehicle |
Year of Vehicle |
Model of Vehicle |
Vin # of Vehicle |
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1 |
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2 |
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3 |
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4 |
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5 |
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6 |
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Liability Limits/Uninsured Motorist Limits |
Personal Injury |
Medical |
Comp |
Collision/Class |
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1 |
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2 |
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3 |
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4 |
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5 |
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6 |
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Part 3 - Your Family's Current Homeowners
Insurance
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Company & Effective Date |
Type of Building |
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Dwelling Insured for What Amount |
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Contents Insured for What Amount |
Policy Form Type
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Location of Dwelling |
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Deductible on Fire & Hazard |
Liability Limits |
Medical Limits |
Flood Coverage |
Wind & Hail Coverage & Deductible
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Part 4 - Your Current Business & CGL
Insurance |
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Company & Effective Date |
Building Description |
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Property Insured for What Amount and What is the Liability Coverage? |
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Contents Insured for What Amount |
Type of Coverage |
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Location |
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Part 5 - Your Family's Current Health,
Disability, Life, Critical Illness & Long Term Care Insurance |
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Health Insurance Company & Effective Date |
Deductible |
Premium |
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Benefits |
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Disability Insurance Company & Effective Date |
Monthly Income |
Premium |
Elimination |
Benefit Period |
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1 |
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2 |
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3 |
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Life Insurance Company & Issue Date |
Insured Name |
Premium |
Face Amount |
Coverage Type |
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1 |
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2 |
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3 |
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4 |
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Critical Illness Insurance Company & Issue Date |
Insured Name |
Premium |
Benefit |
Policy Type |
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1 |
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2 |
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Long Term Care Insurance Company & Issue Date |
Insured Name |
Premium |
Daily Benefit |
Benefit Period/Elimination |
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1 |
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2 |
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Coverage Types for above LTC Policies |
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Life Insurance Needs Analysis |
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Estimate the last expenses (funeral, doctor bills, hospital bills, etc) for
each spouse
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Spouse 1 $ |
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Spouse 2 $ |
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Estimate total of personal bills, not including mortgage, such as bank loans,
credit cards and car loans that would be outstanding in the event of the death
of a spouse. |
$ |
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What is the outstanding mortgage or mortgages the surviving spouse would be
responsible for? |
$ |
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What is the amount of income that would be lost in the event of a death of a
spouse? |
Spouse 1 $ |
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Spouse 2 $ |
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To figure out how much money will be needed to educate your children, use
this formula: |
# of kids
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x # of total school years |
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x estimated $ per year
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Total needed for education fund to get all kids through
school
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Disability Needs Analysis |
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In order to determine if there is a need for replacement income, three
important questions should be answered.
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How long can you go without a paycheck?
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How much is your present monthly income?
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How much of your monthly income would you need to be
replaced in the event of a disability?
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Thank you for taking the time to fill out this review form. The
information gathered will not be shared with any other organization or
individual.
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Expand on any of the above questions here: |
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