Insurance Worksheet – Brian J. Evans Financial Services

Insurance Worksheet

Personal Life Insurance

Name

First Name

Last Name

Immediate Money Fund (Burial, Attorney, Taxes Fed & Prov, Medical)

Debt Liquidation (Credit Cards, Auto Loans, Renovation Loans, etc.)

Emergency Fund (Unexpected bills, major repairs, etc.)

Mortgage/Rent Payment

Child/Home Care Fund Amount per year $

x years

Child/Home Care Total

Child/Home Care Fund Spouse Amount per year $

x years

Child/Home Care Spouse Total

Educational/Vocational Fund

To be set-aside for Future Income Needs

Other Extraordinary Costs

Please list any additional costs

Other Extraordinary Costs 1

Other Extraordinary Costs 2

Other Extraordinary Costs 3

Other Extraordinary Costs 4

Other Extraordinary Costs 5

Subtotal

Liquid Assets Available at Death

Group Insurance

Personal Policies

Mortgage Insurance

Other?

Other Cost

Estate Required at Present

I would like to discuss Children’s Rider or Head Start Policies

I would like to discuss Mortgage Insurance Pros/Cons

Disability Insurance

Gross Monthly Income

Insurable DI Income (x 65%)

Income From Current Assets

Group DI Coverage

Personal Policies

Disability Income Required

Critical Illness Insurance

Should I/We Become Critically Ill (Heart Attack, Stroke, Etc.)

Age 18-55 7 x Annual Income

Age 56-60 5 x Annual Income

Age 61-65 3 x Annual Income

Assets Set Aside for Extraordinary Costs

Group Coverage

Personal Policies

Critical Illness Required

Business Insurance Needs

Insuring your business is an important decision and may be more involved than personal coverage. Business Coverage (Buy Sell, Keyman, etc.) should be discussed with advice from your accounting and legal counsel. We are pleased to facilitate these discussions.

I would like to consider/review the Insurance requirements for my business.

Phone

Options

I want to submit my form for review by Brian J. Evans AND receive my own copy via email

I want to use my form for my own personal use and NOT submit to Brian J. Evans for review

If you are human, leave this field blank.

905-852-3184

Personal Life Insurance

Other Extraordinary Costs

Disability Insurance

Critical Illness Insurance

Hours

Address

Contact

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