WMAIA Needs Analysis

You can always press Enter⏎ to continue

Now create your own Jotform - It's free!Create your own Jotform

Create your own JotForm

JotForm

JotForm mascot Podo

Wealth Matters

Needs Analysis

17Questions

1
Name
First Name
Last Name
2
Email
example@example.com
3
Phone Number
Area Code
Phone Number
4
What is your preferred method of contact?
E-mail
Phone call
SMS chat
5
Date of birth
Date
Day
Month
Year
6
Your annual income before taxe.g. $90,000
7
Do you have a dependent spouse?A dependent spouse is one who depends on you to provide for them financially.
YESNO
8
How many children do you have?e.g. 2
9
What is the age of your youngest child?
10
Value of you and your partners assets that you are prepared to cash in?I.e. You will require less insurance if you use your own assets to offset debts, etc. Do not include any assets that you would want to keep.
Cash
Investment property
Investment property
Shares
Total super balance
Other investment assets
11
You and your partner's debts that you want cleared with your insurance benefitI.e. Do not include amounts that you don't want to be paid out for any reason.
Mortgage
Car loan
Credit card
Other loans
12
The following questions will ask you how much you would need for certain contigencies.

You may either input your own amounts or rely on our suggestions.

Our suggestions will take into consideration – your age, family situation (spouse, children, etc.) to calculate what sort of contingencies you should have.
13
Amount to cover the loss of your income (per year)e.g. $90,000
Our suggestion (your current salary)
14
Select your level of cover for premature death
Low - Covers your debts, no income replacement
Medium - Covers your debts and some partial income replacement
High - Covers all your contingencies and full income replacement
None
15
Select your level of cover for being temporarily unable to work due to injury or illness
Low - Covers your debts, no income replacement
Medium - Covers your debts and some partial income replacement
High - Covers all your contingencies and full income replacement
None
16
Select your level of cover for being permanently unable to work due to injury or illness
Low - Covers your debts, no income replacement
Medium - Covers your debts and some partial income replacement
High - Covers all your contingencies and full income replacement
None
17
Select your level of cover for being diagnosed with a major critical illnesse.g. cancer, stroke, heart attack, etc.
Low - Covers your debts, no income replacement
Medium - Covers your debts and some partial income replacement
High - Covers all your contingencies and full income replacement
None
Should be Empty:

Question Label

1 of 17See AllGo Back

Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Please enter a valid email address.

Something went wrong while saving your answers. Please try again.

Email has been sent successfully.

Save your progress

OR

Already have an account? LOGIN

Skip Create an Account

Save your progress

Name

Email Address

Password

I agree to theTerms of ServiceandPrivacy Policy

Your form submission has been saved as a draft.

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Save your progress

OR

Username or email

Password

Forgot Password?

Your form submission has been saved as a draft.

We’ve sent you an email with a link to complete your submission.