Agent Email *

General/Family Information

First Name *

Last Name *

Phone *

Work Email *

Agent: I already have your name, phone number, and email. Would you like to add a personal email as well?

Personal Email

Date of birth *

Professional Title

Years of Service *

Did you work anywhere else that had a retirement account for you? *

Which building do you work in at __________ school district?

What age would you like to retire *

Do you have a spouse or a significant other? *

Spouse Name

Spouse Birthday

Spouse Occupation

if something happened to you, do you feel its important that (name) understands how all this works?

Do you have any children? *

Children Ages

General Information Notes

Income

Transition: Let's talk about what your income will look like in retirement

Current Annual Income *

Spouse Annual Income

Are you and your spouse married filing jointly or separately?

Do you have a paystub you can take a screenshot of and text to me? We do paystub reviews to help you understand where the money is going and if you may be paying for extra services you don’t need

When age are you taking social security?

Social Security Amount

The national average we need to save for retirement is 15-20% of our salary into retirement based accounts. You are already doing the mandatory into the state pension, so most try to save 10% into their voluntary savings to fill that needed amount. (DO THE MATH of 10% times their salary now divided by 12 months).

How close can you get to that if not already doing so?

Factor ____ into analysis *

Income Section Notes

Assets

How much are you contributing to your 403(b)? *

403(b) Company

403(b) Contribution

403(b) Account Value

What is the purpose of your 403(b), a large purchase, leaving a legacy or income in retirement?

Second 403(b)

How much are you contributing to your second 403(b)?

Second 403(b) Company

Second 403(b) Contribution

Second 403(b) Account Value

What is the purpose of your second 403(b), a large purchase, leaving a legacy or income in retirement?

401(k) Account

How much are you contributing to your 401(k)?

401(k) Company

401(k) Contribution

401(k) Account Value

What is the purpose of your 401(k) account, a large purchase, leaving a legacy, or income in retirement?

Second 401(k)

How much are you contributing to your second 401(k)?

Second 401(k) Contribution

Second 401(k) Company

Second 401(k) Account Value

What is the purpose of your second 401(k) account, a large purchase, leaving a legacy, or income in retirement?

IRA Account

How much are you contributing to your IRA?

IRA Company

IRA Contribution

IRA Account Value

What is the purpose of your IRA account, Large Purchase, Leaving A Legacy, or  Income in Retirement?

Second IRA

How much are you contributing to your second IRA?

Second IRA Company

Second IRA Contribution

Second IRA Account Value

What is the purpose of your second IRA, a large purchase, leaving a legacy, or income in retirement?

Roth IRA Account

How much are you contributing to your Roth IRA?

Roth IRA Account Value

Roth IRA Company

Roth IRA Contribution

What is the purpose your Roth IRA, a large purchase, leaving a legacy, or income in retirement?

Second Roth IRA

How much are you contributing to your second Roth IRA?

Second Roth IRA Company

Second Roth IRA Account Value

Second Roth IRA Contribution

What is the purpose of your second Roth IRA, a large purchase, leaving a legacy, or income in retirement?

Brokerage Account

How much are you contributing to your Brokerage Account?

Brokerage Company

Brokerage Contribution

Brokerage Account Value

What is your purpose of your Brokerage account, a large purchase, leaving a legacy, or income in retirement?

Second Brokerage Account

How much are you contributing to your second Brokerage?

Second Brokerage Company

Second Brokerage Contribution

Second Brokerage Account Value

What is your purpose of your Second Brokerage account, a large purchase, leaving a legacy, or income in retirement?

Other Accounts

How much are you contributing to an "other account"

Other Company

Other Contribution

Other Account Value

What is the purpose of your other account, a large purchase, leaving a legacy, or income in retirement?

Assets Section Notes

Does (spouse name) have any of these accounts that you'd like to add to your analysis?

Savings

It’s good to have at least 3-6 months of expenses in your savings account for emergency purposes? Do you have at least $15k?

Savings Account Contribution

What is the purpose of your savings account?

Debt

Transition: Now that we know what is coming in, let's talk about what is going out...

Do you Rent or Own your Home? *

How much your Rent / Mortgage payment?

How many years are left on the mortgage?

If something happened to you, how much would need to be paid off so (spouse name and kids names) can stay in the home without financial stress?

All of your monthly expenses combined, what do you think that approximate amount would be? *

Credit Cards

Do you carry any credit card balances?

How many credit cards do you have?

How much is your total credit card debt?

How much is your total credit card debt monthly payment?

Student Loans

How much is your total private student loan debt?

How much is your total private student loan monthly payment?

Other

Description of Other Debt

How much is your total other debt?

Is this Debt a lot of pressure for you?

Yes

Debt Section Notes

Insurance

Transition: Finally, the last piece of the retirement circle, financially speaking paint me a picture of what would happen if you didn’t come home from work or your spouse didn’t come back home from work today?

Insurance Section Notes

How much privately own life insurance do you have outside of your job?

Tell me a little bit about that. Is there a health issue that has prevented you from getting coverage in the past? Did you just not know where to turn because there are different types out there and you weren’t sure which fit your picture perfectly? Or has someone just never sat down with you to go over options?

Term Policies

Term Company

Term Insured Party

Term Policy Length

Term Issue Date

Term Life Policy Monthly Premium

Term Life Policy Death Benefit

Do you have a term policy?

Does this term policy also cover your spouse?

Does this term policy also cover your children?

Does your term policy also include living benefits and what I mean by living benefits is, a way to use a large portion of your death benefit while you are alive?

Do you have a second term policy?

Second Term Company

Second Term Insured Party

Second Term Issue Date

Second Term Life Policy Monthly Premium

Second Term Life Policy Death Benefit

Second Term Policy Length

Does this second term policy also cover your spouse?

Does this second term policy also cover your children?

Does your second term policy also include living benefits and what I mean by living benefits is, a way to use a large portion of your death benefit while you are alive?

Whole Life Policies

Do you have a whole life policy?

Whole Life Policy Insured Party

Whole Life Monthly Premium

Whole Issue Date

Whole Life Policy Death Benefit

Does this whole life policy also cover your spouse?

Does this whole life policy also cover your children?

Does your whole life policy also include living benefits and what I mean by living benefits is, a way to use a large portion of your death benefit while you are alive?

Do you have a second whole life policy?

Second Whole Company

Second Whole Life Policy Insured Party

Second Whole Issue Date

Second Whole Life Policy Death Benefit

Does this second whole life policy also cover your spouse?

Does this second whole life policy also cover your children?

Does your second whole policy also include living benefits and what I mean by living benefits is, a way to use a large portion of your death benefit while you are alive?

Variable/Other Life Policies

Do you have a variable policy?

Variable Company

Variable Insured Party

Variable Issue Date

Variable Monthly Premium

Variable Policy Death Benefit

Does this variable policy also cover your spouse?

Does this variable policy also cover your children?

Does your variable policy include living benefits and what I mean by living benefits is, a way to use a large portion of your death benefit while you are alive?

Do you have another Life Insurance Policy?

Other Insured Party

Other Life Company

Other Issue Date

Other Monthly Premium

Other Policy Death Benefit

Does this other policy also cover your spouse?

Does this policy also cover your children?

Does your other policy also include living benefits and what I mean by living benefits is, a way to use a large portion of your death benefit while you are alive?

Goals for Our Next Meeting

Goal #1 for Next Appointment

Goal #2 for Next Appointment

Goal #3 for Next Appointment

Goal #4 for Next Appointment

Goal #5 for Next Appointment

Goal #6 for Next Appointment

Goal #7 for Next Appointment

Second Appointment Date

Goals Notes