Wealth4Us – Start Building Intake Form

Please complete the information below so we can match you with the best protection and retirement strategy for your family.

Step 1

About You

First Name *

Last Name *

Date of birth *

Phone *

Email *

Spouse/Partner Info

(if applicable)

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Step 2

Family & Goals

Do you currently have any life insurance? *

Yes

No

Maybe

Who are you protecting? (check all that apply) *

Myself

Spouse/Partner

Kids

Business

Other

Mention Other if applicable

What matters most right now? (check all that apply) *

Affordable Protection

Cash Value Growth

Legacy Planning

Business Protection

Retirement Income Security

Step 3

Health Snapshot

Do you use Smoke? *

Yes

No

Rate Your Health *

Poor

Fair

Good

Excellent

Any major health conditions? (check all that apply) *

Diabetes

High Blood Pressure

Cancer

Heart Disease

Other

None

Height: *

Weight: *

Step 4

Protection Preferences

Monthly budget you’re comfortable with *

$100

$100–$250

$250

Coverage preference *

Term Insurance

Whole Life / IUL

Not Sure Yet – Show me both

Add spouse/partner coverage too? *

Yes

No

Step 5

 Retirement Snapshot

Are you currently contributing to a retirement plan at work? *

Yes

No

Does your employer match contributions? *

Yes

No

Not sure

If yes, what % do they match?

Do you have previous retirement accounts (401k, 403b, TSP, etc.)? *

Yes

No

Do you currently have an annuity or pension plan? *

Yes

No

Ideal retirement age *

55

60

65

70

Not Sure

Biggest concern about retirement (check all that apply) *

Running out of money

Taxes

Market crashes

Healthcare costs

Leaving a legacy

Spouse/Partner Retirement Snapshot

(if applicable)

Does your spouse currently contributing to a retirement plan at work?

Yes

No

Does your Spouse employer match contributions?

Yes

No

Not sure

Spouse If yes, what % do they match?

Do your Spouse have previous retirement accounts (401k, 403b, TSP, etc.)?

Yes

No

Do your Spouse currently have an annuity or pension plan?

Yes

No

Step 6- Wrap-Up

What’s your top financial priority in the next 12 months? *