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First Name
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Last Name
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Email
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Insurance RX™ helps you understand your insurance protections, spot potential gaps, and prepare for a licensed review. It takes 5–20 minutes, depending on the coverage areas you choose. It is beneficial to have your policy declarations pages or monthly premiums readily available; you may also find it helpful to review the emailed example.
Do you own or rent the place where you are currently living?
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Own
Rent/Lease
Other
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How many cars do you have in your household?
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1
2
3
4+
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Do you have a significant other?
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Yes
No
Other
How many people depend on you for food and shelter (include your mate and yourself in the total)?
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Do you own or operate a business, if so, what kind?
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Do you currently have active health insurance?
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Yes
No
What type of health plan is it?
Employer
Marketplace/ACA
Medicare
Medicaid
Other
What is your annual in-network deductible?
What is your maximum annual out-of-pocket limit?
Are your primary doctors and preferred hospitals in-network?
Does your plan cover prescriptions and major procedures (e.g., surgery, maternity) adequately?
Have you delayed care in the past 12 months due to cost?
When did you last have health insurance?
Are you familiar with Marketplace, COBRA, or Medicaid options available to you?
Do you currently have any life insurance (employer or individual)?
Yes
No
What is the total death benefit amount?
Is it term, whole, or universal life?
How long until the policy term expires?
Is the benefit designed to cover all major needs—income replacement, mortgage, college funds?
Do you know your current family’s total financial need if you were no longer here?
Have you ever owned life insurance before?
Would you like to calculate how much coverage your family would need today?
Do you have any disability income protection through work or a private policy?
Yes
No
Is it short-term, long-term, or both?
What percentage of your income would it replace, and for how long?
Does it cover off-the-job accidents or illnesses?
If you were unable to work for 6 months, how would you cover living expenses?
Would you like to review options for affordable income protection?
Do you currently have auto insurance in force?
Yes
No
What are your current liability limits (e.g., 100/300/100)?
Do you have comprehensive and collision coverage?
Have you had any claims or rate changes in the last year?
Do you have homeowners or renters insurance?
Yes
No
What is the dwelling coverage limit?
Do you carry replacement cost or actual cash value coverage?
Do you have endorsements for valuables (jewelry, electronics, etc.)?
Are you currently contributing to any retirement savings plan (401k, IRA, pension)?
Yes
No
How much are you contributing each month or year?
What is your current total retirement savings?
At what age do you hope to retire, and what annual income do you want?
Have you calculated whether your savings track with your retirement income goal?
Do you have any former employer plans (401k, pension) that haven’t been rolled over?
Would you like to estimate the monthly savings needed to meet your desired retirement age and lifestyle?