Personal Profile Date * : Advisor: First Name * : Last Name * : Middle Name: Address: City * : Province * : BC AB SK MB ON Postal Code: Email Address * : Date Of Birth * : Place Of Birth: Occupation: Employer: Marital Status * : Single Married Common-Law Civil Union Seperated Divorced Spouse Income: $ Smoking Status * : N/A Yes No Earned Income * : $ Children: Own: Rent: Monthly Commute Cost: $ Other Income * : $ Assets Not Available to Produce Income Cash Bank Chequing * : $ Residence Value * : $ Household Furnishings * : $ Automobiles * : $ Recreation Equipment * : $ Other * : $ Assets Available to Produce Income Cash Bank Savings * : $ Real Estate * : $ Stocks Securities * : $ RRSP TFSA * : $ RESP * : $ Company Pension * : $ Business Interest * : $ Other * : $ Loans Lines Of Credit And Mortages Mortgage * : $ Loans * : $ Credit Balances * : $ Other * : $ Office Overhead Expenses Monthly Overhead * : $ Personal Insuarance Personal Life Insurance Term * : $ Personal Life Insurance Permanent * : $ Group Life Insurance * : $ Credit Insurance Mortgage * : $ Critical Illness Insurance * : $ Personal Disability Insurance * : $ Group Disability Insurance * : $ Overhead Disability Insurance * : $ Anticipated Rate Of Inflation * : 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% 13% 14% 15% 15+% Anticipated Rate Of Interest * : 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% 13% 14% 15% 15+% Anticipated Rate Of Investment Return * : 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% 13% 14% 15% 15+% % of Income to Replace at Death or Disability * : 60% 65% 70% 75% 100% Include In Calculation * : Yes No Priorities to Discuss Life Insurance * : 1 2 3 Critical Illness * : 1 2 3 Disability Insurance: 1 2 3 To Discuss Personal Life Insurance: Yes No N/A Spousal Life Insurance: Yes No N/A Childrens Protection: Yes No N/A Disability Insurance: Yes No N/A Critical Illness Recovery Insurance: Yes No N/A Mortgage Insurance: Yes No N/A Updating Of Current Policies: Yes No N/A Partnership Business Insurance: Yes No N/A Estate Planning: Yes No N/A Ability To Qualify For Insurance: Yes No N/A All That Apply Smoker: Yes No N/A Non Smoker: Yes No N/A Health Concerns: Yes No N/A Maritial Status: Yes No N/A Family Status: Yes No N/A Career Job Change: Yes No N/A Plans To Move: Yes No N/A Hazardous Activities: Yes No N/A Estimate