Life Insurance Needs Assessment

Complete this after your initial appointment request. It helps a broker prepare a preliminary needs analysis. It is not an insurer application, quote, binder or policy.

1. Quick intake complete

2. Detailed assessment

Sensitive information

Health and financial information entered here is used for broker review and is stored separately from the public client dashboard. Do not enter a SIN, banking information, credit-card number or full beneficiary details.

Reference number

Email or phone used on your request

Financial needs

Annual earned income

Spouse / household income

Mortgage balance

Other debt

Approximate liquid / investment assets

Financial dependants

Education funding need

Existing individual life coverage

Employer / group life coverage

Approximate monthly premium budget

Desired income replacement period

Who is expected to own the policy?

Existing coverage & replacement review

Could new coverage cause an existing life policy to be cancelled, reduced, replaced or materially changed?

Who is the proposed insured?

A “Yes” or “Not sure” answer is flagged for broker review. The website does not complete a replacement declaration.

Preliminary underwriting screening

Height

Weight

Nicotine / tobacco / vaping in the past 12 months?

Any diagnosed condition requiring ongoing treatment or monitoring?

Any prescription medication currently taken?

Hospitalization or surgery in the past 5 years?

Significant family medical history?

Occupation

Hazardous occupation or duties?

Hazardous sport / aviation / diving?

Regular or planned extended foreign travel / residence?

Material driving or licence issues the broker should discuss?

Optional context for the broker

This is preliminary broker intake only. Eligibility, premiums and coverage remain subject to insurer underwriting, application questions, policy wording and acceptance.

I expressly consent to Frank Insurance collecting and using the health and financial information I provide for insurance-needs assessment and broker review. I expressly consent to Frank Insurance disclosing this assessment to the assigned licensed broker and, if I ask to proceed with insurance options, to insurers, MGAs and underwriting partners where reasonably necessary for quotation, eligibility or underwriting review. I understand this website does not bind coverage and is not the insurer’s application.

Open client status