Gethsemane™ Personal Protection Assessment Advice Over Sales™

Understanding your circumstances, exposures, and priorities is the first step toward developing a thoughtful protection strategy.

Estimated Completion Time: 10-15 Minutes

This assessment is designed to help us better understand your household, personal property, liability considerations, and protection priorities. It is not an insurance application and does not bind coverage.

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- Step 1 of 6

1. Household & Family Profile

Help us understand your household and the people who depend on it.

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Name *

First

Last

Date of Bith *

Employment Status *

Nature of Occupation *

Marital Status *

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Household Size *

Do you have anyone who depends on your income or financial supprt? *

Who depends on your income? *

Spouse
Minor Children
Adult Children
Parents
Other Family Members
Business Partners
Other

Youngest Dependent Age Range *

Oldest Dependent Age Range *

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Which best describes your current living situation? *

Own primary residence
Rent primary residence
Live with family
Other

Which of the following best describe your household? (Check all that apply)

Teen Drivers
College-Aged Children
Aging Parents
Special Needs Dependents
Businessowner
Self-Employed
None of the Above

2. Asset Protection

Help us understand the assets, property, and exposures that may require protection.

Which of the following do you own or have a financial interest in? *

Primary Home
Vacation / Seasonal Home
Rental Property
Vacant Land
Business Property
None of the Above

Which of the following do you own or regularly use? *

Vehicles
Motorcycle
Boat / Watercraft
RV / Camper
ATV / UTV
Golf Cart
Other Recreational Vehicle
None of the Above

Have you purchased, inherited, sold, renovated, or otherwise experienced a significant change in assets or property within the past three years? *

Yes
No
Unsure

Please briefly describe the change. *

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How confident are you that your current protection strategy reflects your current assets and responsibilities? *

What contributes to your level of concern or uncertainty?

You may include concerns regarding your insurance program, changing family circumstances, assets, income, liability exposure, or other factors.

3. Income Protection

Help us understand how your household may be impacted by a temporary or permanent interruption of income.

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Which best describes your household income structure? *

Primarily one income earner
Two income earners
Multiple income sources
Prefer not to answer

If your primary household income stopped unexpectedly, how long could your household maintain its current lifestyle without making significant changes? *

How confident are you that your household could recover financially from a long-term illness, injury, or disability affecting a primary income earner? *

Very Confident
Somewhat Confident
Unsure
Not Very Confident
Not Confident At All

What contributes to your concern or uncertainty?

Have there been any significant changes to your income, occupation, business interests, or employment situation within the past three years? *

Yes
No
Unsure

Please briefly describe the change.

Which potential financial concerns are most important to you? (Check all that apply) *

Loss of income
Disability or illness
Job loss
Business interruption
Retirement readiness
Long-term care expenses
Caregiving responsibilities
Other

Have you recently evaluated how a loss of income could affect your household's financial goals and obligations? *

Yes
No
Unsure

4. Responsibility Exposure

Help us understand personal, family, property, business, and community responsibilities that may create financial or legal exposure.

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Which of the following apply to your household? (Check all that apply) *

Swimming Pool
Trampoline
Pets
Household Employee (Au Pair, Nanny, Caregiver, Housekeeper, etc.)
None of the Above

Do you currently serve in any of the following capacities? (Check all that apply) *

Business Owner
Partner or Shareholder
Corporate Officer
Board Member
Church Leadership
Nonprofit Leadership
Coach or Mentor
Volunteer Leader
None of the Above

Do you own property or assets that may be used, occupied, or accessed by others? *

Yes
No
Unsure

Have you recently considered how a significant legal claim or financial obligation could affect your household, assets, or future plans? *

Yes
No
Unsure

How confident are you that your current protection strategy reflects your responsibilities and potential exposures? *

What contributes to your concern or uncertainty?

Which areas would you like to better understand or discuss? *

Family Responsibilities
Property Responsibilities
Automobile-Related Responsibilities
Volunteer or Leadership Responsibilities
Business Responsibilities
General Risk Management
I'm Not Sure
None At This Time

5. Protection Priorities & Goals

Help us understand what is most important to you and where you may benefit from additional discussion, review, or planning.

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What are most important to you to protect? (Check all that apply) *

My Family
My Income
My Home
My Assets
My Lifestyle
My Business
My Future Retirement
My Legacy
Other

Please Describe.

Which areas would you most like to better understand or review? (Check all that apply) *

Asset Protection
Income Protection
Family Protection
Responsibility Exposure
Retirement Considerations
Long-Term Care Considerations
Business Protection
Estate & Legacy Considerations
General Protection Review
Not sure

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How confident are you that your current protection strategy aligns with your long-term goals and priorities? *

What contributes to your concern or uncertainty?

Which of the following life events may occur within the next five years? (Check all that apply) *

Marriage
New Child
Child Leaving Home
College Funding
Home Purchase
Home Sale
Retirement
Business Start-Up
Caring for Aging Parents
Significant Lifestyle Changes
None of the Above

What is your greatest protection-related concern today?

Connection & Next Steps

A few final questions to help us better understand how we connected and how to best communicate with you moving forward.

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Email *

Phone Number *

Preferred Method of Contact? *

Call
Email
Text

Phone Type *

Home
Cell
Work / Business

How Did You Hear About Gethsemane™? *

Which platform? *

Facebook
Instagram
Youtube
TikTok
Other

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Please tell us who referred you. *

Please tell us the name of the Church or business? *

If other, please describe how you heard about Gethsemane™. *

Do you have a Referral Code ID?

If you were provided a Referral Code ID by an eligible referring organization, please enter it here.

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Have you attended a Gethsemane™ presentation or workshop? *

Please tell us how you heard about us.

Gethsemane™ Personal Protection Assessment Advice Over Sales™

1. Household & Family Profile

2. Asset Protection

3. Income Protection

4. Responsibility Exposure

5. Protection Priorities & Goals

Connection & Next Steps

Quick Links

Legal & Compliance