First Name *

Last Name *

Email *

Phone *

Date of birth

Personal Cash flow data

Monthly Income: $
Less Taxes (@20%): $
Monthly after-tax income: $
Monthly debt payments: $
Monthly debt percentage: %
Spouse Name:
Your Spouse's Phone:
Your Spouse's Email:
Date of Birth: spouse
Number of Children / ages
Number of Grandchildren / ages
Do you intend to send your children/grandchildren to college? yes / no
Personal Residence: Principal & Interest Only: $
Property Taxes: $
Homeowners Insurance: $
Mortgage: Principal amt
Interest % / Type (fixed/ARM/interest only) / min pmt / actual pmt

Debt data (long term - LT / short term - ST)

1. LT: Name / Principal / int % / min pmt / actual pmt
2. LT: Name / Principal / int % / min pmt / actual pmt
3. LT: Name / Principal / int % / min pmt / actual pmt
1. ST: Name / Principal / int % / min pmt / actual pmt
2. ST: Name / Principal / int % / min pmt / actual pmt
3. ST: Name / Principal / int % / min pmt / actual pmt
4. ST: Name / Principal / int % / min pmt / actual pmt
5. ST: Name / Principal / int % / min pmt / actual pmt
6. ST: Name / Principal / int % / min pmt / actual pmt
7. ST: Name / Principal / int % / min pmt / actual pmt
8. ST: Name / Principal / int % / min pmt / actual pmt
9. ST: Name / Principal / int % / min pmt / actual pmt
10. ST: Name / Principal / int % / min pmt / actual pmt
Would you postpone retirement savings if you could eliminate debt sooner and end up with more in retirement?
Which concerns you more, the growth in your savings or protection against loss of savings?
Do you want a retirement plan controlled solely by you or subject to government influence?
Are you currently working with a financial advisor?

Existing Life insurance

Do you have any existing individual life insurance policies and/or annuity contracts in force?
If yes, the total amount of existing insurance in force is
1. Company / Policy # / Type (permanent/term) / Amount / Year issued / Replace?
2. Company / Policy # / Type (permanent/term) / Amount / Year issued / Replace?
3. Company / Policy # / Type (permanent/term) / Amount / Year issued / Replace?
4. Company / Policy # / Type (permanent/term) / Amount / Year issued / Replace?
5. Company / Policy # / Type (permanent/term) / Amount / Year issued / Replace?
Do you have any pending individual life insurance policies and/or annuity contracts?
Is the policy applied for intended to replace, in whole or in part, any existing life insurance or annuity?

Monthly Income Type

Wages/Salary ($)
Projected Annual Salary Increase (%)
Social Security ($):
Pension:
Rental Income:
Other Income:
Total Income:
Desired Retirement Income:
Required Income Projection
Desired Retirement Age
Have you considered cost-of-living, inflation, and increased medical expenses?
Do you expect a significant income or cash flow change in the near future?
Cashflow change: Bonus ($)
Cashflow change: Gifts ($):
Cashflow change: Tax Refund ($)
Cashflow change: Inheritance ($) :
Cashflow change: Other ($)
Projected Monthly Social Security Income Age 62 ($/mo)
Projected Monthly Social Security Income Age NRA ($/mo):
Projected Monthly Social Security Income Age 70 ($/mo)

Accounts available (Savings, Checking, 401(k), 403(b), 457, 529, IRA, Roth IRA, UTMA/UGMA, etc.):

1. Institution / Type / Value / Contributions / Avail yes/no
2. Institution / Type / Value / Contributions / Avail yes/no
3. Institution / Type / Value / Contributions / Avail yes/no
4. Institution / Type / Value / Contributions / Avail yes/no
5. Institution / Type / Value / Contributions / Avail yes/no

Financial questions

Would you postpone retirement savings if you could eliminate debt sooner and end up with more in retirement?
Which concerns you more, the growth in your savings or protection against loss of savings?
Do you want a retirement plan controlled solely by you or subject to government influence?
Are you currently working with a financial advisor?
If so, whom and for how long? ______ years
Do you have a Will, Living Will, General Power of Attorney and Healthcare Power of Attorney?
Does your spouse have a Will, Living Will, General Power of Attorney and Healthcare Power of Attorney?
Do you have a concern about Long Term Care needs in the future
Do you own more properties than just your personal residence?

File upload

Agent of record (who is your agent? or no one) *

How did you find us? *