Consumer Insurance Advocates
NEEDS ASSESSMENT
AGENT NAME ______DATE______
Name______Date of Birth ______Age ______
Occupation______Company______Years of Service ______
Spouse Name______Date of Birth ______Age ______
Occupation______Company ______Years of Service ______
Address______
Phone (home) ( ) ______(work) ( ) ______Fax ( ) ______
Email______
Emergency Contact Name______Phone ( ) ______
Children Age City Grandchildren Age
______
______
______
______
MEDICAL EXPENSES
1.Many people are concerned about their health and the high cost of health care. What are you doing to protect yourself? ______
2. Is being able to qualify for health insurance a concern of yours? ______
3. What type of health insurance do you have now? ______
Company______Plan______Riders______Premium______
Prescription Coverage? Yes No
Company______Plan______Riders______Premium______
4. What are your concerns about the gaps in your healthcare coverage like dental, hearing, and vision? ______
5. If you could change anything about your present health coverage, what would it be? ______
CRITICAL ILLNESS/HIP
6. Do you have a means of paying for unplanned catastrophic medical expenses such as a diagnosis of cancer, a stroke, an extended hospital stay or heart attack? May I ask why not?
______
LTC (Over 45)/DISABILITY (Under 45)
7. Do you know anyone who has dealt with Long Term Care/Disability? How did it affect them? ______
8. Most people have three concerns regarding Long Term Care/Disability: protecting their assets, having choices, and remaining independent. Please tell me your concerns. ______
______
9. Many people are also concerned about becoming an emotional and/or financial burden on their children. How do you feel about that? ______
______
FINAL EXPENSES/TRIBUTE DIRECT
10. Do you own any life insurance? Yes No May I ask why not?
Face Amount: Insured______Spouse ______Beneficiary ______
Company: Insured ______Spouse ______Beneficiary ______
Premium: Insured ______Spouse ______
11. What are your plans for life insurance? Why do you have it? ______
12. Have you pre-planned your funeral or cremation? Yes No May I ask why not?
13. When was your plan last reviewed? Does your NOK/Decider know exactly what you want and what to do? ______
14. Many people wonder if their death will create an estate tax($1M or more) problem for their heirs. Is that a concern ofyours? Yes No
15. Do you have a special bank account, trust or investment fund that was set up for a specific purpose such asproviding an income for your spouse, or establishing legacy money for grandchildren’s educations and/or leaving money to charity? Yes No
RETIREMENT INCOME/SAVINGS
16. Many people are concerned that Social Security does/will not provide an adequate retirement income. How do you feel about the uncertainties surrounding these retirement issues?
______
17. When you did/will retire, did/will you qualify for Social Security? (monthly amount)______
A company pension? ______(monthly amount)
18. Are you able to save some money or do you need all of your income to live on? ______
What are your monthly expenditures? ______
19. Share with me your current/future plans for your retirement. ______
______
20. Why have you chosen these types of investments? ______
Are you satisfied with the return on your investments? ______
The information I have provided in this Needs Assessment provides an accurate picture of my current situation andbeliefs. I understand that any recommendations made by the agent are based on these responses.
Signature______Date______
In a presentation conducted by me on behalf of Consumer Insurance Advocates, I recommended the following insurance products. ______
______
Agent Signature______Date______
NOTES ______
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