Full Name
Date of birth
*
Occupational status
*
Choose one or more options
Marital Status
*
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Number of dependents
*
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Federal income tax bracket
*
10%
12%
22%
24%
32%
35%
37%
Financial experience
Stock
Certificates of deposit
Savings account
Fixed annuity
Variable life insurance
Term life insurance
Bonds
Money market account
Mutual funds
Variable annuity
Life insurance with cash value
Spouse Information
Spouse's full name
Occupation
Spouse's occupation status
Choose one or more options
Spouses Date of Birth
Expected retirement age
Email
*
Phone
*
Address
Street Address
City
State
Country
Enter your country
Postal Code
Annual Income
*
Sources of Income (Check all that apply)
Salary/wages
Investment income
Trust income
Rental income
Alimony
Pension/RMD
Social Security
Disability income
Severance
Other
Estimated Net Worth
*
Annual Living Expenses
*
Deaths and obligations
Emergency funds
Current assets
Mutual funds
Stocks
Bonds
IRA/Roth IRA
Money Market/Brokerage
401k/403b/SEP/SIMPLE
Life insurance (Term)
Life insurance (Cash Value)
Fixed annuities
Fixed index annuities
Variable annuity
Savings account
CDs
Real estate
Other
Retirement age
*
Time Horizon (Ex: 10,20, 30yrs)
*
Required Annual Requirement Income
*
Financial Objectives (check all that apply)
Income now (supplement your current income with an additional income stream starting immediately)
Income later (supplement your income in the future, after it accumulates for several years)
Cover spouse's lifetime
Principal protection (safely grow your money with a reasonable rate of return and access to your money)
Long-term growth (grow your money with the possibily better rate of return for long period of time with less liquidity)
Pass assets to heir
Reduce the effects on inflation (medicate the loss of purchasing power as time passes in the cost of goods and services go up)
Income tax deferral (let your investments grow tax-free until retirement)
Probate avoidance (avoid probate and simplify the transfer of assets)
Potential for better returns (seek potentially higher returns link to market performance)
Do you have an estate plan in place?
Yes
No
What's that?
Insurance needs (check all that)
Life insurance
Long-term stability coverage
Health insurance
Other
Investment Risk Tolerance (How much risk are you willing to accept?)
Choose one or more options
Funding source (which asset are you going to use to fund the insurance product(s)?)
*
Checking/Savings
Stocks/bonds/mutual funds
Life insurance
Annuity
CD
401(k) or other retirement accounts
Other
Future major changes
Future large expenses