Your Information

Age (Years): Coverage Amount ($):

$50,000

Health Condition: Excellent Good Average Poor Do you smoke? No Yes Family History of Illness: No Yes Annual Deductible ($):

$1,000

Premium Analysis

Monthly Premium: $0

Yearly Premium: $0

Personal Details

Age Gender Male Female Number of Dependents

Income and Financial Obligations

Annual Income Existing Savings & Investments Outstanding Debts

Future Needs

Children’s Education Costs Spouse’s Income Replacement Funeral and Final Expenses Medical Expenses

Life Expectancy

Expected Age at Death