LS INSURANCE SERVICE | Life Insurance Form

Life Insurance

SPEND A MOMENT FILLING OUT THIS WORKSHEET PROVIDED BY LSI,
WHILE YOUR INSURANCE NEED MAY SEEM STAGGERING, IT'S MORE AFFORABLE THAN YOU THINK.

First Name

Last Name

Phone Number

Email Address

Date of Birth:

Gender

Smoker?

Enter all figures in whole numbers (Example: 100000 or 100000.00). This form will do the math for you.

A) Current Annual Living Expenses: $

B) Annual On-Going Part/Grandparent Care: $

C) Projected Annual Child-Care Costs: $

D) Total Annual Expenses = A+B+C: $

E) Annual Income of Surviving Spouse! $

F) Annual Social Security Benefit (if known): $

G) Total Annual lncome = E+F: $

H) Annual Expected Shortfall = D+G: $

I) Other Annual Debts you will have: $

J) Estimated Funeral Expenses: $

K) Annual Uninsured Medical Expenses: $

L) Children's Annual Future Medical Needs: $

M) Subtotal of Annual Expenses = I+J+K+L: $

N) Annual Expenses Shortfall = H x 10 Years: $

O) Total 10 Year Expenses = M+N: $

P) Existing Life lnsurance: $

Q) Incoming-Producing Annual Assets: $

R) Cash and Savings Accounts: $

S) Annual Social Security Benefit: $

T) Total Annual Assets = P+Q+R+S: $

TOTAL INSURANCE NEEDED: $

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