Life Insurance Needs Analysis
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Jacob Campbell Insurance Agency

By completing and submitting this Life Insurance Needs Analysis, you authorize Jacob Campbell Insurance Agency and its licensed agents or representatives to contact you at the phone number or email address you provided. This may include calls, emails, or other forms of communication regarding life insurance options, quotes, or related services.

You acknowledge that filling out this needs analysis is not a condition of purchasing any insurance product and that you may revoke your consent at any time by notifying us. You further understand that any information provided will be used solely for the purpose of assisting with your life insurance needs and may be shared with relevant licensed agents or partners to offer appropriate products.

For any questions or to opt out of further communications, please contact us at 405-388-6611
Your Full Name *
Your Date of Birth *
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Phone Number? *
Your Full Address *
Email Address? *
Are you Married?
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Do you have children?
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Occupation and Employer?
What is the main reason you are considering life insurance? (E.g., income replacement, debt coverage, estate planning, final expenses)  
How long would you like your life insurance coverage to last? (e.g., until your children are grown, until a mortgage is paid off, for retirement)  
What would you like your beneficiaries to do with the death benefit (e.g., pay off debts, invest, save for future needs)?  
Would you like your life insurance policy to have a cash value or investment component (e.g., whole life insurance)?  
Do you have any current life insurance coverage? (e.g., employer-provided, individual policy)  
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If yes, what type of coverage do you have? (Term, Whole Life, Universal Life, etc.)  
What is the current coverage amount and policy term?  
 Do you have any pre-existing medical conditions (e.g., diabetes, heart disease)?  
Do you smoke or use tobacco products? (This can affect premiums)  
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How would you describe your overall health? (Excellent, Good, Fair, Poor)  
Do you engage in any high-risk activities (e.g., extreme sports, flying, etc.)?  
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Are you currently taking any prescription medications? If so, what for?  
How much coverage do you feel you need? (Think about such things as covering debts, income replacement, education, and future expenses)
What are you comfortable paying for premiums each month?  
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