FINANCIAL EVALUATION FORM

COMPLEMENTARY FINANCIAL EVALUATION

(Confidential) Fill out the form carefully for proper follow up
Today’s Date

MonthDayYear
Date
How Do You Spell Your Name?*

First NameLast Name
Phone Number*
Email Address
example@example.com
Would you consider it to be ________ to provide financial security for your financial future:*

UnimportantImportantExtremely Important
Do you have an updated will/trust?*

YesNo
Do you currently have life insurance?*

YesNo
If we can save you money on your policy, and/or give you a free upgrade, would that be something you would be open to?*

YesNo
If you qualify for the upgrade:*

would you prefer paying the same and getting more coveragestaying with the same coverage and paying less
Does your company provide you with a retirement plan?*

YesNo
If Yes, What Kind?
401K,403B,457 ect..
Are you currently participating in it?*

YesNo
Are you contributing to any retirement plans outside of work?

YesNo
If we lower your fees to your retirement plan, would that be something you would be open to?*

YesNo
Do you already have a Financial Advisor?

YesNo
Are you open to a 2nd Opinion if it would improve your Financial Strategy?

YesNo
Outside of tomorrow, at what age would you like to retire?*
When will money work for you, so you no longer work for money
What is your current age?*
When will money work for you, so you no longer work for money
How much money do you think you would need per month to retire comfortably, and stay retired?*
When will money work for you, so you no longer work for money
Are you on track to reach that goal?

YesNoUnknown
If we, can show you a surefire way to be on track, would you be open to it?

YesNo
If we could improve your financial situation, which of the following would you like to learn more about? Please Check all That Apply*

Life Insurance/Protection For My FamilyPersonal Pension Plan401k/IRA RolloverEmergency FundCollege Education FundsEstate/Legacy PlanningFree Personal/Business Financial CheckUpHow to Help & Educate My Family/FriendsEarn More Income
What Day & Time Can We Contact You To Schedule A Financial Check Up? *
(Date & Time, Location, Within 24-48 Hrs.) Office, Home, Other
Should be Empty:

COMPLEMENTARY FINANCIAL EVALUATION