15 + Years Serving the Community
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26-241 Clarence St,
Brampton, ON L6W 4P2
Coverage Need
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+1 416-707-9900 |
| Total Life Insurance Needed | |
|---|---|
| Prepared For:___________ | |
| Prepared By:___________ | |
| Immediate Cash Needs | |
| Mortgage & other debts Balance to pay of | $0 |
| Emergency Fund | $0 |
| Education Fund | $0 |
| Final Expenses | $0 |
| Future Income Needed | |
|---|---|
| What is your annual income (Before taxes)? | $0 |
| % of current income required for survivor | 0% |
| Annual income needed for survivor | $0 |
| Number of years income required | 0 |
| Interest rate (Inflation adjusted) | 0% |
| Total Future Income Needs | $0 |
| Liquid Assets | |
|---|---|
| Personal Life Insurance | $0 |
| Group Life Insurance | $0 |
| Pension Plan / CPP Death Benefit | $0 |
| Bonds, Stocks and Mutual Funds | $0 |
| Real Estate (Other than home) | $0 |
| Other Available Assets | $0 |
| Cash On Hand (Savings) | $0 |
| Total Liquid Assets | $0 |
| Total Coverage Needs | |
|---|---|
| Total Immediate Cash Needed | |
| Total Lost Income Needs | |
| Total Cash Available | |
| Total Coverage Needs (Rounded) | |
| I acknowledge that the client has given the consent to process the personal data in accordance with the terms of the compliance department. Based on the region selection above, the data will be controlled by the advisor and will not shared with anyone else. | |
| CHOICES | |
| O Client was presented with this needs analysis and client decided to purchase an insurance for the amount of $................... | |
| O The client did not want to go through the needs analysis process and knew the amount of coverage they wanted | |
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Conflict of Interest It is my duty to disclose any conflict of interest with respect to my overall recommendations, to you, as my client. As an Independent Broker, I am bound by the laws governing life insurance agents in the province of ___________ and the Code of Ethics of my professional association, Independent Financial Brokers of Canada. This means that any insurance/financial products I recommend, will be what I deem best suited to meet your needs without regard to compensation practices of any one company. |
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Acknowledgement Your signature on this form acknowledges that you have received this information and do not waive any legal rights you may have. Should you require further information, or if you have a complaint, I will assist you personally, or direct you to the appropriate resource. “I have been informed of, and understand the products & services offered by________________________and understand the implications of this disclosure including any conflict, or potential conflict of interest associated." |
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Agent Name: Phone email: Dated this |
Client's Signature: Agent Signature |
