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435 N Whittington Pkwy Ste 135, Louisville, KY 40222
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Home
About Us
Our Team
Services
Contact Us
(859) 484-8313
Contact Us
Get A Quote
Need’s Analysis
Death & Debt
The amount needed to create an immediate expense fund and pay off any outstanding debt (auto loan, credit card, student loan, final expense costs, etc.)
Mortgage
The amount needed to pay off any outstanding balance on your mortgage or replace your rent for several years
Education
The amount needed for you children’s college education
Income
The amount needed to replace your income
Years
Income for how many years?
Lump Sum Needed
Less Current Assets
Total Lump Sum Needed
Total Income Needed
Total Need
This worksheet is a tool to assist you in estimating your basic life insurance needs. It is not intended to provide a thorough and comprehensive analysis of your life insurance needs or to recommend a specific amount of type of coverage. The actual amount of life insurance you need will depend on several factors that you need to consider carefully. Your insurance professional can assist you with analysis of your personal circumstances.
Personal Data
Client Name
(Required)
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
(Required)
Email
(Required)
Client's Date of Birth
(Required)
Month
Day
Year
Client's Social Security Number
Client's Employer
Client's Annual Income
Children's Name
Children's Date of Birth
Month
Day
Year
Children's Name
Children's Date of Birth
Month
Day
Year
Children's Name
Children's Date of Birth
Month
Day
Year
What programs do you currently have in place?
Client's Savings Account
Client's Money Market
Client's Certificate of Deposit
Client's Tax-Deferred Annuity
Client's Mutual Funds
Client's Stocks / Bonds
Client's IRA / 401(K) / Roth / Pensions / Old 401(k)s
Client's Other (Inheritance)
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Add for Sum
Life Insurance
Client
Individual: Type
Term
UL
VUL
WL
Employer: Type
Term
UL
VUL
WL
Client's Individual DB:
Client's Employer DB:
PX:
Co.
Individual: Type
Term
UL
VUL
WL
Client's Individual DB:
PX:
Co.
This field is hidden when viewing the form
Total Life Insurance
This field is hidden when viewing the form
Less Current Assets
Spouse
This field is hidden when viewing the form
Type: Individual
Term
UL
VUL
WL
This field is hidden when viewing the form
Type: Employer
Term
UL
VUL
WL
This field is hidden when viewing the form
DB:
This field is hidden when viewing the form
DB:
This field is hidden when viewing the form
PX:
This field is hidden when viewing the form
Co.
This field is hidden when viewing the form
Individual: Type
Term
UL
VUL
WL
This field is hidden when viewing the form
DB:
This field is hidden when viewing the form
PX:
This field is hidden when viewing the form
Co.
Health Insurance
Yes
No
Disability Income
Yes
No
Prem:
Prem:
Long Term Care
Yes
No
Medicare Supp.
Yes
No
Prem:
Prem:
Notes
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