Family Protection Assessment Form

Protection Evaluation Document

Jonathan McDonnell is regulated by the Central Bank of Ireland. We will never share your data with any other 3rd party without your consent. To find out more about how we manage your data, you can view our data privacy statement on our website: www.qualifiedfinancialadvisor.com

Question Title

* 1. Enter Your Name, Email and Phone Number here

Name:

Email:

Phone:

Question Title

* 2. What is your date of birth?

Date of Birth

Date

Question Title

* 3. Have you smoked any form of tobacco or E-cigarette in the last 12 months?

Yes

Question Title

* 4. What do you need Family Protection for? (You can select various options)

To protect a loan / mortgage

For my final expenses (funeral costs etc)

To protect my family from my death

To replace my income for my family if I die

Question Title

* 5. Is the Protection for you alone or for you and another person?

Single

Joint

Question Title

* 6. If this is a Joint Policy Quote. Please provide the Name, Date of Birth and Smoker status of the second person.

Name

Date of Birth

Smoker OR Non-Smoker

Question Title

* 7. Approximately how much cover do you think you will need?

Between - €25,000 and €75,000+

Between - €100,000 and €200,000+

€300,000 +

I'm not sure, I'll need your advice on that.

Question Title

* 8. How many children do you have?

Question Title

* 9. What age is your youngest child?

Question Title

* 10. If you had died or suffered from a life altering illness yesterday, how much money every month would your family need to keep up their current standard of living?

€1,500 a Month

€2,000 a month

€2,500 a month

€3,000 a Month

€3,500 a month

Other (please specify)

Question Title

* 11. Are there any special circumstances which should be taken into account when completing this ﬁnancial review? For example recent illness, bereavement, any diffculties in following the review due to hearing or sight problems, redundancy, retirement or maybe if you ﬁnd ﬁnancial discussions confusing?

YES, Please detail below:

Question Title

* 12. This quote information sheet is being conducted by Jonathan McDonnell, Qualified Financial Advisor. By submitting your answers, you agree that we may contact you regarding your answers and further with email marketing communications. You are also consenting to the storage of this information and we will use it only to provide you with advice. We never share your data to third parties without your consent. You may unsubscribe from our communications at any time.

I Agree