The first step in your Needs Analysis is this Client Information Questionnaire or what we call The Biker R.I.P. - Roadmap Intake Packet.

It is a series of short questions that enable us to obtain a brief overview of your personal and business (if appropriate) situation.

This information will help your Advisor provide you with proactive planning recommendations.

You can be assured that your answers to the questions remain 100% confidential at all times.

Once your have completed the Form, you will be directed to a calendar request to schedule time with Jennifer to review the results and discuss your Options.

We appreciate and value your trust in us and look forward to proactively working with you for many years to come.

Primary Contact Information

What is your Gender? *

Female

Male

Your Date of Birth *

Any Current Medications? *

Any medical conditions? *

Who Depends on You?

Dependents, family, or people who would be impacted financially if something happened to you.

Spouse/Partner Contact Information

Spouse/Partner First Name

Spouse/Partner Last Name

Spouse/Partner's Gender

Female

Male

Spouse/Partner's Date of Birth

Tobacco Use spouse

Tobacco User

Non-Tobacco User

Spouse/Partner's current medications?

Spouse/Partner's medical conditions?

Minor Children Contact Information

Do You have Minor Children? *

Yes

expecting

please comment below the Gender and Ages of Minor Children.

Minor Children Gender(s) and Age(s)

Interested in the Following Information either now or in the future and would like to learn more about how these can support of personal financial plan *

Additional Comments:

Primary Contact Email Address *

Best Phone to Reach You *

State Where You Live *

a. Do you currently have life insurance in place on yourself? *

b. What type of life insurance is in place for you? *

c. Do you currently have life insurance on your spouse? *

d. What type of life insurance is in place for your spouse? *

e. Are you interested in looking at Insurance policies for Accumulation (with living benefits to supplement retirement) or increased death benefits to support the family after you have gone? *

Yes Accumulation and Living Benefits

Yes Increased Death Benefit for my heirs

Yes, Headstart policy for minor Children or Grandchildren

All of the Above

Not at this time

What was your household income last year? (This information is extremely confidential and is only used in consideration of our Tax Strategy recommendations) This is not a required field but we can discuss this further when we meet.

1a. Gross Household Income

1b. What was your taxable income for last year?

Income this year compared to last year?

2a. Do you expect your gross Household income to change this year?

2b. Please use this text box to provide some background where you anticipate changes and why.

Estimated Personal Net Worth

3a. What is your estimated Personal Net worth (approximately) excluding any business value?

Please provide a breakdown of your personal assets by category and (approximate) value.

Personal Real Estate *

Commercial Real Estate *

Stocks and Bonds *

Cryptocurrency *

Personal Cash *

Other (specify in this text box)

Other Asset Value (referenced above)

3b. Are you considering selling any personal asset worth $1M (or more) in the next 12 months? *

3c. What is you credit score? (This can qualify you different insurance products... please select one of the ranges below). *

Retirement & Investment Assets

4a. Do you have any of the following ? Please check all that apply *

4b. Other (specify in this text box)

4c. Personal Net Worth: If you want to add additional information, please use this text box.

4d. Retirement & Investment: If you want to add additional information, please use this text box.

Wills & Trust Planning

5a. Do you currently have a will in place? *

5b. How long ago was it reviewed? *

5c. Do you currently have a Trust/Pour-over will? *

5d. Do you currently have a Power of Attorney or Healthcare directive? *

6a. What are the Current Liabilites we need to consider and cover? Please check all that apply *

Your Key Advisors

Our goal is to provide you with proactive and truly helpful with our advice. To allow us to be truly supportive it is helpful to know who you regard and currently rely on as key advisors.

Please complete the information below for each of your "key advisors". If you have none please type N/A and continue.

The rating scale is 1 for poor to 5 for excellent.

7a. Key Advisor and Profession (banker, insurance, accountant, attorney, CFP, Etc.)

Personal Rating for Advisor above in 7a.

BadGood

7b. Key Advisor and Profession (banker, insurance, accountant, attorney, CFP, Etc.) (copy)

Personal Rating for Advisor above in 7b.

BadGood

7c. Any other Comments regarding Key Advisors?

Business Interest (if applicable)

8a. Do you own or have financial interest in a business or Non-Profit? *

Yes

8b. We can schedule time following our initial meeting to discuss the Business Strategies Solutions we offer Small business owners. Would you be interested in Learning more? *

Yes

Maybe

Current Hazards & Risks Coverage

9a. Insurance & Protection already in place *

10a. Cash Savings/CDs available for Emergencies. *

1-3 months

3-6 months

6 + months

Non

Where do you want be (Short Term & Long Term):

11a. Short-Term (1-3 years): *

11b. Long-Term Goals (5-20 years): *

11c. Your Planning Style: *

Conservative & steady

Balanced

Aggressive growth

"Just tell me what works"

Your Priorities and Personal Wishes:

12a. Your Legacy Priorities: *

12b. Personal Notes or Wishes

When you submit this form we will contact you to schedule your Review...

Please have copies of the following for our meeting:

Existing insurance policies
Beneficiary designations
Retirement account statements
Mortgage/loan statements (if applicable)
Business documents (if applicable)
Any estate planning docs you already have

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