Organization
*
Officers
1. Name / Date of Birth / Sex
2. Name / Date of Birth / Sex
3. Name / Date of Birth / Sex
4. Name / Date of Birth / Sex
Business Address
*
FEIN / SS
Entity Type
Sole Proprietorship
S- Corporation
LLC, Taxed as Sole Proprietorship
LLC, Taxed as S- Corporation
C-Corporation
Partnership
LLC, Taxed as C-Corporation
LLC, Taxed as Partnership
Other
Business Stage
Concept
Growth
Sale in (# years)
Start-up
Stable
Additional business concerns
Supplemental Insurance Benefits
Gap plan: Yes / no
Disability: Yes / no
Accident: Yes / no
Chronic/Critical illness: Yes / no
Dental: Yes / no
Cancer: Yes / no
Vision: Yes / no
Medicare eligible: Yes / no
Benefit Bank
Vacation/Sick leave
401(k)
Wellness Programs
How are benefit programs decided on in your company?
How are enrollments communicated to employees?
Benefits asked for by employees, but not offering?
What would you NOT change about your benefits?
Who are your competitors?
What makes you stand out as far as benefits?
Who would your employees come to in financial distress?
Do feel like your company experiences an abnormal amount of Workers Compensation claims?
Do you used a third party administrator for premium deductions?
Are you a union, association, or PEO (Professional Employer Organization)
Do you have multiple locations to service?
Is separate billing required?
Who is the billing representative?
Billing representative contact (Name, phone, email)
What day of the week does payroll process?
Business Property & Casualty Coverage
Liability: Carrier / Effective date / key coverages
Property: Carrier / Effective date / key coverages
Business Auto: Carrier / Effective date / key coverages
Workers Compensation: Carrier / Effective date / key coverages
Business Umbrella: Carrier / Effective date / key coverages
Floaters, Endorsements, tools, etc: Carrier / Effective date / key coverages
EPLi (practices) and EBLi (benefits): Carrier / Effective date / key coverages
Business Cashflow Data
Annual Cash Flow: $
Minimum Monthly Cash Flow: $
Max. Monthly Cash Flow: $
Line of Credit?
Reserves on Hand: $
Retained Earnings $
Monthly Salary $
How bills are paid: LOC or cash
Do you expect a significant future change in cash flow?
Do you distribute bonuses?
Business Debt
1. Debt name / Amt / int % / min pmt / actual pmt
2. Debt name / Amt / int % / min pmt / actual pmt
3. Debt name / Amt / int % / min pmt / actual pmt
4. Debt name / Amt / int % / min pmt / actual pmt
5. Debt name / Amt / int % / min pmt / actual pmt
6. Debt name / Amt / int % / min pmt / actual pmt
7. Debt name / Amt / int % / min pmt / actual pmt
8. Debt name / Amt / int % / min pmt / actual pmt
9. Debt name / Amt / int % / min pmt / actual pmt
10. Debt name / Amt / int % / min pmt / actual pmt
Retirement Plan
Is there a business-sponsored retirement plan?
Who is included? owner, employee, both
Do you have any other plans (ie, key person/executive bonus)
Personal Monthly Contribution: $
Is there an employer match?
If so, what is the match?
Has a tax analysis been performed to optimize your current retirement plan
Outside investment options
1. Institution / Acct type / Value $ / Monthly contrib / Avail yes or no
2. Institution / Acct type / Value $ / Monthly contrib / Avail yes or no
3. Institution / Acct type / Value $ / Monthly contrib / Avail yes or no
4. Institution / Acct type / Value $ / Monthly contrib / Avail yes or no
5. Institution / Acct type / Value $ / Monthly contrib / Avail yes or no
6. Institution / Acct type / Value $ / Monthly contrib / Avail yes or no
7. Institution / Acct type / Value $ / Monthly contrib / Avail yes or no
8. Institution / Acct type / Value $ / Monthly contrib / Avail yes or no
9. Institution / Acct type / Value $ / Monthly contrib / Avail yes or no
10. Institution / Acct type / Value $ / Monthly contrib / Avail yes or no
Life Insurance benefits
Overall health - preferred, standard, substandard
Tobacco user - yes/no
Type: Permanent / term / employer
Premium
Death Benefit
Cash value
File upload
Agent of record (who is your agent? or no one)
*
How did you find us?
*
Referral
Agent
TV
Website
LinkedIn
Facebook
Tiktok
Instagram
Other
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