Name:
Email:
Phone Number: (10 digits,eg. 8005614028)
Date of Birth (mm/dd/yyyy)
January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Gender:
Male
Female
How would you rate your current health?
Poor
Below Average
Average
Above Average
Great
Do you smoke any tobacco products?
Yes
No
What is your current weight?
lbs < 75
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
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108
109
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285
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316
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328
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351
352
353
354
355
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360
361
362
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364
365
366
367
368
369
370
371
372
373
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377
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379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
> 400 lbs
What is your current height?
4'0"
4'1"
4'2"
4'3"
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
7'1"
7'2"
7'3"
7'4"
7'5"
7'6"
7'7"
7'8"
7'9"
7'10"
7'11"
What state do you live in?
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
How many years of life insurance protection are you looking to get?(Enter 100 if you want lifetime protection)
5
10
20
30
100
How much death benefit protection do you think you need to apply for?
$
0
100,000
250,000
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
Describe the face amount, years of coverage left on the policy, policy type, and premium for all life insurance policies you currently have. Include any comments or questions you have(eg. $500,000 face amount 17 year term policy for a $1,000/yr)
Death Benefit Analysis
Colva Insurance Services provides a free Death Benefit Analysis which involves an actuary looking at your net worth and your beneficiaries' financial needs and determining how much Death Benefit Protection you should obtain in order to protect your beneficiaries' financial interests. While this is an optional service, Colva strongly recommends that its clients have this free analysis done. Having a financial professional assess your current financial obligations and discuss your needs with you can help save thousands of dollars in premium or prevent you from leaving beneficiaries without enough protection.
Would you like Colva Insurance Services to help you determine how much Death Benefit protection you need and what product best suites you? (If no, hit the "submit quote request" button below. Otherwise answer questions below)
Yes
No
Background Questions
Why and for whom are you looking to buy life insurance for at this time in your life?
How much life insurance do you currently have on your life?
$
0
100,000
250,000
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
At what age do you plan on retiring?
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
Do you expect your net worth to be greater than $1 million at any time in the future?(Note that death benefit proceeds from life insurance are tax-free. However, estate values in excess of $5.12 million are currently taxed upon death at 35%. In 2013 this limit will be $1 million and the tax rate will be 55%)
Yes
No
Outstanding Debt Questions
What is the current outstanding balance on your mortgage?(Enter 0, if you are renting)
$
What is the current interest rate on your mortgage?(Enter 0 if you are renting)
How many years are left on your mortgage loan?(Enter 0 if you are renting)
What is the current total outstanding balance on your student loans?
$
What is the current total outstanding balance on your car loans?
$
What is the current total outstanding balance on your credit cards?
$
What is the current total outstanding balance on any other debt you have?
$
Asset Value Questions
What is the current market value of your home? (Enter 0, if you are renting)
$
What is the total value of all your personal checking and savings accounts?
$
What is the total value of your retirement funds/plans?
$
What is the total value of all your stock investments.
$
What is the total value of all your non-stock investments? (second home, rental property, etc)
$
What is the total value of any college savings plans you have for your children?
$
Current Beneficiary Questions
What is the current age of the primary beneficiary?
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
What is the total amount of the beneficiary's monthly after-tax income (e.g. Monthly After-Tax income from Beneficiary's job)?
$
Does the beneficiary live in the same house as the insured?
Yes
No
If answer above is "No", how much is the beneficiary's monthly rent/mortgage payment?
$
Besides rent, what is the total amount of the beneficiary's other monthly living expenses? (e.g.food, gas, entertainment, etc)
$
What percentage of the beneficiaries total expenses will you want to cover? (Enter a number between 0 and 100. Entering 100 means that 100% of the beneficiary's expenses will be provided for through the life insurance policy.)
Future Beneficiary College Expenses
How many of your children are currently/will be going to College in the future?
0
1
2
3
4
Will your children be going to a State, Public, or Private College? State College(eg. SDSU):~$6,500/yr
State
Public
Private
What percent of your children's college expenses do you want your insurance policy to provide for?(Enter a number between 0 and 100. Entering 100 means that your policy will provide for 100% of the costs needed to fund your Children's college costs)
Current Age of College Bound Child1 (Enter age between 0 and 22. Type 0 if not applicable)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Current Age of College Bound Child2 (Enter age between 0 and 22. Type 0 if not applicable)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Current Age of College Bound Child3(Enter age between 0 and 22. Type 0 if not applicable)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Current Age of College Bound Child4(Enter age between 0 and 22. Type 0 if not applicable)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
