Client Review Form

	Part 1  - Your Family's Personal Information
	Members of Household	Birthday	Age	Sex	Occupation
1
2
3
4
5
6
7
8
	Wedding Anniversary Date
	Home Street Address	City	State	Zip	Home Phone
	Business Address	City	State	Zip	Business Phone
	Other Business Address: working spouse				Business Phone
	Cell Phone
	Cell Phone
	E-Mail
	E-Mail
	Part 2 - Your Family's Current Auto Insurance
	Current Insurance Company & Effective Start/End date of Policy	Make of Vehicle	Year of Vehicle	Model of Vehicle	Vin # of Vehicle
1
2
3
4
5
6
	Liability Limits/Uninsured Motorist Limits	Personal Injury	Medical	Comp	Collision/Class
1
2
3
4
5
6
	Part 3 - Your Family's Current Homeowners Insurance
	Company & Effective Date	Type of Building			Dwelling Insured for What Amount
		Single Family Condominium Townhouse Farm Mobile Home
	Contents Insured for What Amount	Policy Form Type			Location of Dwelling
	Deductible on Fire & Hazard	Liability Limits	Medical Limits	Flood Coverage	Wind & Hail Coverage & Deductible
	Part 4 - Your Current Business & CGL Insurance
	Company & Effective Date	Building Description			Property Insured for What Amount and What is the Liability Coverage?
	Contents Insured for What Amount	Type of Coverage			Location
	Part 5 - Your Family's Current Health, Disability, Life, Critical Illness & Long Term Care Insurance
	Health Insurance Company & Effective Date	Deductible	Premium		Benefits
	Disability Insurance Company & Effective Date	Monthly Income	Premium	Elimination	Benefit Period
1
2
3
	Life Insurance Company & Issue  Date	Insured Name	Premium	Face Amount	Coverage Type
1
2
3
4
	Critical Illness Insurance Company & Issue Date	Insured Name	Premium	Benefit	Policy Type
1
2
	Long Term Care Insurance Company & Issue Date	Insured Name	Premium	Daily Benefit	Benefit Period/Elimination
1
2
		Coverage Types for above LTC Policies
	Life Insurance Needs Analysis
	Estimate the last expenses (funeral, doctor bills, hospital bills, etc) for each spouse	Spouse 1  $			Spouse 2 $
	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.	$
	What is the outstanding mortgage or mortgages the surviving spouse would be responsible for?	$
	What is the amount of income that would be lost in the event of a death of a spouse?	Spouse 1 $			Spouse 2 $
	To figure out how much money will be needed to educate your children, use this formula:	# of kids
		x # of total school years
		x estimated $ per year
		Total needed for education fund to get all kids through school
	Disability Needs Analysis
	In order to determine if there is a need for replacement income, three important questions should be answered.	How long can you go without a paycheck? 30 days 90 days 6 months 1 year indefinetly
		How much is your present monthly income?
		How much of your monthly income would you need to be replaced in the event of a disability?
	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.	Expand on any of the above questions here: