Insurance Worksheet

Please fill out the form below to the full extent of your abilities. The more information we obtain from you, the more we will be able to help going forward!

Full Name

Preferred Contact Method

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Current Insurance

Category

Company

Value

Cost/Month

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Total Costs/M:

Categories:

Health Insurance Provider

Life Insurance

Dental Insurance

Homeowners/Renters Insurance

Auto Insurance

Long Term Care Insurance

Vision Insurance

Medicare Supplemental/Advantage

Disability Insurance

Business Insurance

Other Insurance

How would you describe your health?  

If you were to get news that you are going to die in a few months what would you do? 

How much monthly income would you have if you became disabled today? 

Do you have a will or a trust? 

Who can we put down as a trusted contact person (name & phone): 

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TODD MANN FINANCIAL SERVICES INC. 
1840 5th St. Springfield, OR 97477  |  (O) 541-583-0093  |  Todd@ToddMannFinancialServices.com

Investment advice is offered through Belpointe Asset Management, LLC. Insurance and annuity products may be offered through D.H. Hill Securities, LLLP. Securities are offered through D.H. Hill Securities, LLLP, Member FINRA/SIPC. D.H. Hill Securities, LLLP, Todd Mann Financial Services Inc., and Belpointe Asset Management, LLC are not affiliated entities. Todd Mann Financial Services Inc. is currently insurance licensed in the states of Oregon, New Jersey, and Wisconsin.

Insurance and annuity products may be offered through D.H. Hill Securities, LLLP. 

 

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