Phone: (09)
418 5000
Toll-free ph:
0800 54 33 84
E-mail:
Advice@LIFE-TIME.co.nz
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Individual Financial Health Check
Your information
Name:
Date of Birth:
I am paid by:
---
PAYE
drawings/dividends
combination of both
Annual Income:
Smoking Status:
---
non-smoker 12 mos
Smoker
Occasional cigar only
Health Satus:
---
excellent
good
fair
poor
Do you have any pre-existing conditions:
---
Yes
No
If yes, please list:
Are you on any medication:
---
Yes
No
If yes, please list:
Your Partner's information
Partner's Name:
Date of Birth:
Your partner is paid by:
---
PAYE
drawings/dividends
combination of both
Annual Income:
$
Smoking Status:
---
Non-smoker for past 12-months
Smoker
Occasional cigar only
Health Satus:
---
excellent
good
fair
poor
Does your partner you have any preexisting conditions:
---
Yes
No
If yes, please list:
Are you on any medication:
---
Yes
No
If yes, please list:
Financial Information
Approximately what percentage of your total household income do you and your partner earn?
You:
Your Partner:
How dependent is your household on your income?
---
Totally
Mostly
Somewhat
Not at all
How depandent are you for your partner's income?
---
Totally
Mostly
Somewhat
Not at all
Do you have an alternative source of income that you could live on if you were unable to work?
Yes
No
If yes please give details:
How long would this alternative income continue for?
---
0 to 6 months
6 to 12 months
1 to 3 years
3 to 5 years
ongoing
How long would your savings last if you were unable to work?
---
1 week
2 to 3 weeks
1 to 2 months
3 months
4 months
5 months
6 months
7-12 months
several years
Would your family struggle to get by financially if you died?
Yes
No
Would your family struggle financially if you suffered a long term illness or disability?
Yes
No
Would your family struggle financially if you were totally and permanently disabled?
Yes
No
Would your family struggle to get by financially if your partner died?
Yes
No
Would they struggle financially if your partner suffered a long term illness or disability?
Yes
No
Would they struggle financially if your partner were totally and permanently disabled?
Yes
No
If you or a family member developed a major health problem, is being able to get the treatment needed with greater dependability and speed than the public health system provided important to you?
Yes
No
Insurance Needs Analysis
To determine how much insurance cover you and your family require, we need to identify your financial goals and liabilities as follows:
Existing Liabilities:
How much would it cost to repay all of your personal or family loans?
$
How much would it cost to repay your home mortagage or mortgages?
$
How much would it cost to repay any outstanding H.P. agreements that you have?
$
How much do you owe on your credit or store cards?
$
How much would it cost to repay any investment property mortagages that you have?
$
How much would it cost to eliminate any business debts or liabilities that you have?
$
Enter the amount required to eliminate any other debts or liabilities that you have?
$
Living Expenses:
How much money (after tax) does your family need each month to live as it does now?
$
What extra monthly income would your family need if you were unable to work?
$
What extra monthly income would you need if your partner were unable to work?
$
What monthly income would your family need if you died and all debts were paid?
$
How much money have you put away for emergencies?
$
Education Funding:
For private school and/or university as is appropriate
How many children do you have
What are their ages?
Do you have a special needs child?
Yes
No
How much will it cost in total to send each of your children to a private school?
$
How much will it cost to send each of them to university?
$
Retirement Funding:
If you were to retire today, what annual income would you require to live comfortably?
$
At what age do you want to retire?
What is the approximate value of your present superannuation funds and investment?
$
Do you belong to an employer sponsored superannuation scheme?
Yes
No
Do you belong to a KiwiSaver scheme?
Yes
No
Please advise the name of your KiwiSaver provider and the fund(s) in which you are invested:
Please advise either your fortnightly or monthly contribution or what percentage of your income (eg 2%, 4%, 6% or 8%) you are investing:
Existing Insurance
Please enter below details of any personal insurance policies that you or your partner currently have in place:
Your cover:
Life insurance - How much cover do you currently have in place on your life?
$
Critical Illness or Trauma cover - How much cover do you currently have?
$
Total & Permanent Disability cover - How much cover do you currently have?
Income Protection:
What type of policy do you have:
Indemnity
Agreed Value
What is the monthly benefit:
$
How long is the waiting period or No Pay Period?
---
2 weeks
4 weeks
8 weeks
13 weeks
26 weeks
52 weeks
104 weeks
How long will the benefit be paid for?
---
2 years
5 years
to age 60
to age 65
to age 70
Your Partners Cover:
Life insurance - How much cover do they currently have in place on their life?
$
Critical Illness or Trauma cover - How much cover do you currently have?
$
Total & Permanent Disability cover - How much cover do you currently have?
$
Income Protection:
What type of policy do you have:
---
Indemnity
Agreed Value
What is the monthly benefit:
$
How long is the waiting period?
---
4 weeks
8 weeks
13 weeks
26 weeks
How long will the benefit be paid for?
---
2 years
5 years
to age 60
to age 65
to age 70
Health Insurance:
Who is covered on this policy?
---
Single person
Couple
Single Parent Family
Family
Does it pay for G.P. visits?
Yes
No
Does it pay for Specialists and Tests?
Yes
No
Does it pay for Dental & Optical?
Yes
No
What is the excess on the policy?
---
Nil
$250
$300
$500
$600
$1000
$2000
$4000
$5000
$6000
$10000
Following up with you
Preferred method of contact:
---
Home Phone
Business Phone
Mobile Phone
Email Address
Contact number or email address:
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