FINANCIAL NEEDS ANALYSIS

PERSONAL INFORMATION
Date DD MM YY CUSTOMER SPOUSE
First name

Last name
Sex Male Female Male Female

Marital status Married Common-law spouse Single Divorced Other:

Date of birth DD MM YY Age: DD MM YY Age:

Smoking status Yes No Health status: Yes No Health status:

Residential address
Municipality Province Postal
code
E-mail E-mail

Own Rent Since:

Res. ( ) Cell.: ( ) Res. ( ) Cell.: ( )
Telephone No.
Work ( ) ext.: Work ( ) ext.:

Employer
Occupation / trade
Any changes planned? Yes No Yes No
Annual income $ Source: $ Source:
$ Source: $ Source:
Last will and Testament Yes No Holographic Made in the presence of witnesses Yes No Holographic Made in the presence of witnesses
Notarized Notarized
Living will Yes No Yes No

Hazardous Sports Yes No Yes No

Child’s Name Date of birth RESP Child’s Name Date of birth RESP
DD MM YY DD MM YY
DD MM YY DD MM YY
LIFE, CRITICAL ILLNESS OR LONG-TERM CARE INSURANCE POLICIES
Company Face amount $
Policy No. Issue date DD MM YY
Policy type Expiry date DD MM YY
Additional benefits Policyowner
Premium mode $
Insured(s)
Beneficiaries

Cash value $ Policy loans $

Company Face amount $

Policy No. Issue date DD MM YY

Policy type Expiry date DD MM YY
Additional benefits Policyowner
Premium mode $
Insured(s)
Beneficiaries

Cash value $ Policy loans $

Company Face amount $

Policy No. Issue date DD MM YY

Policy type Expiry date DD MM YY
Additional benefits Policyowner
Premium mode $
Insured(s)
Beneficiaries

Cash value $ Policy loans $

06040E (06-03)
 LIFE INSURANCE NEEDS ANALYSIS

CUSTOMER FAMILY SPOUSE

Monthly income (before death) $ (1) $ (1)

Monthly savings $ (2) $ (2)

Mortgage payment $ (3) If insured $ (3) If insured

Monthly income requirements (after death) $ (4) 70% of income or 1-[2+3] $ (4) 70% of income or 1-[2+3]

Present income of surviving spouse $ If family $ If family

Pension of surviving spouse (CPP/QPP) $ See grid below $ See grid below

Orphan’s pension (CPP/QPP) $ $195 per child (QPP: $64) $ $195 per child (QPP: $64)

Other income $ $

Total $ (5) $ (5)

% %
Monthly income shorfall (4-5) $ X Factor = $ A $ X Factor = $ A

ASSETS AT DEATH

CPP/QPP benefits $ $2,500 $ $2,500

Residence $ $

Summer cottage and furniture* $ $

Investments* $ $

Life insurance $ Other than mortgage $ Other than mortgage

Group life insurance $ $

Others*: $ $

Total assets $ = $ B $ = $ B

LIABILITIES AND EXPENSES AT DEATH

Mortgage $ If uninsured $ If uninsured

Loan(s) $ $

Income tax $ $

Death-related expenses $ $

Adjustment to new situation $ $

Reserve for education $ $

Other* : $ $

Total liabilities $ = $ C $ = $ C

LIFE INSURANCE REQUIRED (A - B + C) $ (A - B + C) $

* Applicable taxes may be imposed during liquidation/redemption

LIFE INSURANCE CALCULATION FACTOR OBJECTIVES AND COMMENTS

Under 45 years 45 to 54 55 to 64 65 years
years years and over ____________________________________________________________________________
CPP/QPP
Surviving No
____________________________________________________________________________
Spouse’s Disabled Children Child(ren)
Pension $714 $419 $686 $714 $716 $507 ____________________________________________________________________________
Average Rate of return ____________________________________________________________________________
Capital ____________________________________________________________________________
calculation factor 3% 4% 5% 6% 7% 8%
____________________________________________________________________________
5 years 55.79 54.48 53.21 51.98 50.80 49.65 ____________________________________________________________________________
Capital depreciation

10 years 103.82 99.10 94.67 90.52 86.63 82.97 ____________________________________________________________________________

15 years 145.17 135.64 126.98 119.10 111.90 105.34
____________________________________________________________________________
20 years 180.76 165.57 152.16 140.28 129.73 120.35
____________________________________________________________________________
25 years 211.40 190.08 171.77 155.98 142.31 130.43
____________________________________________________________________________
30 years 237.78 210.16 187.06 167.63 151.18 137.19
____________________________________________________________________________
35 years 260.49 226.60 198.97 176.26 157.44 141.73
____________________________________________________________________________
Preservation
of capital 400 300 240 200 171.4 150 ____________________________________________________________________________