Insurance Agent Portal | Goode Coverage

Section 2 — Purpose of Coverage

Understanding why you're seeking coverage helps us tailor the right solution.

Select all that apply:

How long do you need coverage?

Temporary (Term) Permanent Not Sure

Do you have existing life insurance?

YES NO

Section 3 — Insureds

Provide details for each person to be insured.

Smoker Status

No Yes Former

SSN (For application purposes, optional)

Add Additional Insured?

Yes No

Additional Insured Details

Primary Beneficiary(ies)

➕ Add another primary beneficiary

Contingent Beneficiary(ies)

➕ Add another contingent beneficiary

Section 4 — Coverage Expectations

Desired coverage, budget, and rider preferences.

Desired Coverage Amount

Monthly Premium Budget

What matters most?

Riders of Interest

Additional Notes on Expectations

Section 5 —Health History & Underwriting

Your health history helps us identify the best carriers and underwriting class.

Tobacco / Nicotine Use(Current)

YES No

Products used:

Medical History

Are you currently taking any prescription medications?

Yes No

Hospitalized in the past 5 years?

Yes No

Surgery in the past 5 years?

Yes No

Currently under a physician's care?

Yes No

Family Medical History

Father Heart Disease

Mother Heart Disease

Sibling Heart Disease

Section 6—Underwriting Considerations

These questions help identify any factors that may affect insurability or premium class.

Lifestyle / Activities

Do you participate in any of the following?

Driving History (Past 3 yrs)

Reckless driving conviction?

Yes No

More than 2 moving violations?

Yes No

Currently involved in any pending lawsuits?

Yes No

Ever declared bankruptcy?

Yes No

Outstanding tax liens or judgments?

Yes No

Have you traveled to or plan to travel to any country outside the US or Canada in the next 12 months?

Yes No

Active duty military?

Yes No

Occupational Hazards

Does your occupation involve any of the following?

Advisor Notes / Observations

CLIENT SIGNATURE (Type or draw your signature)

AGENT/ADVISOR SIGNATURE (Type or draw your signature)

AGENT/ADVISOR SIGNATURE

This needs analysis form is for informational purposes only and does not constitute a binding insurance contract or guarantee of coverage. Information provided will be used to evaluate insurance options. All information disclosed is treated as confidential and will be used solely for the purpose of assessing your insurance needs.

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Insurance Needs Analysis Form

Insurance Needs Analysis Form

Section 2 — Purpose of Coverage

Section 3 — Insureds

Section 4 — Coverage Expectations

Section 5 —Health History & Underwriting

Medications

Recent Medical Care

Family Medical History

FATHER

MOTHER

Siblings

Section 6—Underwriting Considerations

Lifestyle / Activities

Driving History (Past 3 yrs)

Legal / Financial

Travel

Military Service

Occupational Hazards

Signatures

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