Canadian Term Insurance

Complete our needs analysis form
Referral Program

Name *

Email *

Telephone *

(555) 123-4567

Birth Date

Gender

Male Female

Have you ever smoked? Yes No

Province

Amount of Insurance

Product Type

Health Risk

* Indicates required field
* The quoting process is only a quote and subject to further medical and underwriting requirements

Insurance Needs Analyzer

Fill in the information below and an agent of Canadian Term Insurance will call you to discuss our initial assessment of your insurance needs.

First Name:		*
Last Name:
Email address:		*
Telephone Number:		( ) -
Best Time Of Day To Call:
Income to be replaced if death occurred:	$	.00 *
Estimated annual tax rate: (Combined federal and provincial)		% *

Number of years required for income to be replaced:		years *
(Examples: Until age 65, until age 80, until children have finished post secondary school, until mortgage is paid)
Estimated annual rate of return:		%
(What rate of return would you expect from a conservative investment portfolio over a 30 year period?)
Estimated inflation rate:		%
(What do you expect the average inflation rate to be over the next 30 years?)
What percentage of your net family income is spent entirely on you and not on combined family expenses: (Examples: your car payment, your car insurance, memberships, and leisure expenses)		%
Is there any additional info you woud like to include?

Submit your request for an Insurance Needs Analysis now.

Disclaimer and Notice: Results of a Needs Analyzer will only give a rough estimate of potential insurance needs. Clients should contact our office, complete a Fact Finder and discuss their particular goals with an agent.