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Financial Protection for Life's Path

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Needs Analysis Form

Complete and submit the following information to help us confirm the best health benefits approach for your situation.

Health Benefits - What's Important?

Name

Street Address

Email Address

Type of Coverage Required:

Single

Couple

Family

Date of Birth

City & Postal Code

Phone #

Partner's Date of Birth

Please identify which of the following health benefits are important to you...

Dental?

Yes

Medical Practitioners: (for all that apply, provide average # of visits per year and cost per year)

- Acupuncture?

- Chiropractor?

- Massage Therapy?

- Naturopath?

- Physiotherapist?

- Podiatrist?

- Osteopath?

- Psychologist?

- Speech Therapist?

Vision Care? (includes prescription glasses, contact lenses, and laser eye surgery)

Yes

Orthotics?

Yes

Emergency Medical Travel Insurance?

Yes

If Yes, how many days per trip (on average)?

And how many trips per year (on average)?

List any current long-term prescriptions, including approximate annual cost for each

Thanks for submitting!

Interested in a Complimentary

Insurance Quote?

Thanks for submitting!

FLEXIBLE LOCATIONS!

Virtually serving all of Alberta & British Columbia in the comfort of your home or workplace.

Carolyn Melnychuk, CFP

Email: carolyn@securedfuture.ca

Phone: 780.446.2426

Fax: 780.456.5600

Secured Future: Financial Protection.

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