Confidential Client Information
Client Data
Full Legal Name
First Name
Middle Name
Last Name
Prefix
Mr.
Ms.
Mrs.
Dr.
Today's Date
-
Month
-
Day
Year
Date
Preferred Name
Social Security Number
Social Security Number
Date of Birth
-
Month
-
Day
Year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Address (If Moved within 5 Years)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Confirm Email
example@example.com
Email Confidential?
Yes
No
Preferred Contact Method
Please Select
Cell Phone
Office Phone
Home Phone
Email
Mail(Office)
Mail (Home)
Driver's License Number
Driver's License State
Expiration
Marital Status
Please Select
Single
Married
Separated
Divorced
Widowed
Anniversary Date
-
Month
-
Day
Year
Date
Previous Marriage
Yes
No
Details of Previous Marriage
Employer Information
Employer
Occupation/Title
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Office Email
example@example.com
Confirm Email
example@example.com
Employment Status
Full Time
Part Time
Self Employed
Retired
Years in Current Postion
Name of Assistant (If Applicable)
Assistant's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Assistant's Email
example@example.com
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Spouse Data
Full Legal Name
First Name
Middle Name
Last Name
Prefix
Mr.
Ms.
Mrs.
Dr.
Today's Date
-
Month
-
Day
Year
Date
Preferred Name
Social Security Number
Social Security Number
Date of Birth
-
Month
-
Day
Year
Date
Same as Client
Yes
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Confirm Email
example@example.com
Email Confidential?
Yes
No
Driver's License Number
Driver's License State
Expiration
Preferred Contact Method
Please Select
Cell Phone
Office Phone
Home Phone
Email
Mail (Office)
Mail (Home)
Previous Marriage
Yes
No
Details of Previous Marriage
Employer Information
Spouse
Employer
Occupation/Title
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Office Email
example@example.com
Employment Status
Full Time
Part Time
Self Employed
Retired
Years in Current Position
Name of Assistant (If Applicable)
Assistant's Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Assistant's Email
example@example.com
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Confidential Family Facts
Number of Children from Your Current Marriage
Number of Children from Your Previous Marriage
Number of Spouse's Children from Previous Marriage
Please Enter Information for Each Child
Rows
Child's Name
Address
Date of Birth
SSN
Married?
# of Grandchildren
Child #1
Child #2
Child #3
Child #4
Child #5
Child #6
Child #7
Child #8
Child #9
Child #10
Additional Dependents? Please Explain.
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Parents
Client
Father
Father's Date of Birth
-
Month
-
Day
Year
Date
Alive?
Yes
No
Cause of Death
Health
Excellent
Good
Average
Poor
Mother
Mother's Date of Birth
-
Month
-
Day
Year
Date
Alive?
Yes
No
Cause of Death
Health
Excellent
Good
Average
Poor
Anticipated Inheritance
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Parents
Spouse
Father
Father's Date of Birth
-
Month
-
Day
Year
Date
Alive?
Yes
No
Cause of Death
Health
Excellent
Good
Average
Poor
Mother
Mother's Date of Birth
-
Month
-
Day
Year
Date
Alive?
Yes
No
Cause of Death
Health
Excellent
Good
Average
Poor
Anticipated Inheritance
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Confidential Family Information
Client
1. Are you a citizen of the United States of America?
Yes
No
Additional Comments
2. Are you receiving Social Security, disability or other governmental benefits?
Yes
No
Additional Comments
3. Are you in the active military?
Yes
No
Additional Comments
4. Have you ever lived in a Community Property State?
Yes
No
Additional Comments
5. Have you completed a will, trust or estate plan?
Yes
No
Additional Comments
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6. Are you the beneficiary of any trust or estate?
Yes
No
Additional Comments
7. Do you anticipate a significant inheritance or other significant future financial event?
Yes
No
Additional Comments
8. Have you ever filed a federal or state gift tax-return or made gifts under the Uniform Gift to Minors Act?
Yes
No
Additional Comments
9. Have you every signed a pre- or post-marriage contract?
Yes
No
Additional Comments
10. Have you been widowed or divorced?
Yes
No
Additional Comments
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11. Do you have obligations or are you making payments pursuant to a divorce or Property settlement agreement?
Yes
No
Additional Comments
12. Do you have adopted children?
Yes
No
Additional Comments
13. Do any of your children have special education, medical or physical needs or receive any governmental support benefits?
Yes
No
Additional Comments
14. Are any of your children institutionalized?
Yes
No
Additional Comments
15. Do you provide primary or other major financial support to adult children?
Yes
No
Additional Comments
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16. Do you anticipate needing to support your parents in the future?
Yes
No
Additional Comments
17. Do you have any known litigation issues?
Yes
No
Additional Comments
18. Have you made specific charitable (or other) bequests or commitments?
Yes
No
Additional Comments
19. Do you give annual gifts to a specific charity?
Yes
No
Additional Comments
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Confidential Family Information
Spouse
1. Are you a citizen of the United States of America?
Yes
No
Additional Comments
2. Are you receiving Social Security, disability or other governmental benefits?
Yes
No
Additional Comments
3. Are you in the active military?
Yes
No
Additional Comments
4. Have you ever lived in a Community Property State?
Yes
No
Additional Comments
5. Have you completed a will, trust or estate plan?
Yes
No
Additional Comments
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6. Are you the beneficiary of any trust or estate?
Yes
No
Additional Comments
7. Do you anticipate a significant inheritance or other significant future financial event?
Yes
No
Additional Comments
8. Have you ever filed a federal or state gift tax-return or made gifts under the Uniform Gift to Minors Act?
Yes
No
Additional Comments
9. Have you every signed a pre- or post-marriage contract?
Yes
No
Additional Comments
10. Have you been widowed or divorced?
Yes
No
Additional Comments
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11. Do you have obligations or are you making payments pursuant to a divorce or Property settlement agreement?
Yes
No
Additional Comments
12. Do you have adopted children?
Yes
No
Additional Comments
13. Do any of your children have special education, medical or physical needs or receive any governmental support benefits?
Yes
No
Additional Comments
14. Are any of your children institutionalized?
Yes
No
Additional Comments
15. Do you provide primary or other major financial support to adult children?
Yes
No
Additional Comments
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16. Do you anticipate needing to support your parents in the future?
Yes
No
Additional Comments
17. Do you have any known litigation issues?
Yes
No
Additional Comments
18. Have you made specific charitable (or other) bequests or commitments?
Yes
No
Additional Comments
19. Do you give annual gifts to a specific charity?
Yes
No
Additional Comments
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My Income Statement
Earned Income - Prior Year
Quick View
Unearned Income - Prior Year
Quick View
Earned Income - Current Year
Quick View
Unearned Income - Current Year
Quick View
Expenses
Quick View
Detail View
Rows
Income
Salary
Bonus
Interest
Dividends
Rental Income
Other Investment Income
Retirement Income
Other
Other
Other
Total Income ($)
Rows
Expenses
Debt Repayment
- Mortgages
- Equity Line of Credit
- Other
Insurance
- Life
- Disability
- Long Term Care
- All Other
Contributions
Living Expenses
All Other Expenses
Total Expenses ($)
Net Available for Investments ($)
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My Future Income Sources
Rows
Client
Spouse
Estimated Social Security
Other
Other
Other
Future Income Sources Total - Client
Future Income Sources Total - Spouse
My Income Statement Notes
Optional
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My Balance Sheet
As of:
-
Month
-
Day
Year
Date
Liquid Assets (Cash, etc.) $
Quick View
Debts $
Quick View
Net Worth $
Quick View
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Cash (Liquid) Assets
Rows
Cash (Liquid)
Checking/Savings Account
Money Market Account
Other
Other
Total Cash (Liquid) Assets ($)
Investment Assets
Rows
Investments
Stocks
Bonds
Mutual Funds
CD's
Other
Total Investment Assets ($)
Retirement Assets
Rows
Retirement
401(k)/403(b), etc.
IRA/Roth IRA
Company Pension
Other
Total Retirement Assets ($)
Real Estate Assets
Rows
Real Estate
Home
REITs
Rental/Investment Property
Other Property
Other
Total Real Estate Assets ($)
Business Assets
Rows
Business
Other
Other
Total Business Assets ($)
Other Assets
Rows
Other
Personal Property
Life Insurance Cash Value
Other
Other
Total Other Assets ($)
Total Assets ($)
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Liabilities
Rows
Debts
Home Mortgage
Mortgage #2
Mortgage #3
Home Equity LOC
Credit Cards
Personal Loans
Car Loans
Unpaid Taxes
Other
Other
Other
Other
Other
Other
Total Liabilities ($)
Net Worth ($)
Off Balance Sheet Liabilities
Rows
Liabilities
Health Care for Family
College Education
Charitable Pledges
Long Term Care
Projected Taxes
Other
Total Off Balance Sheet Liabilities ($)
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Advisors and Mentors
Accountant
Rows
Personal
Business
Name
Address
Phone
Email
Attorney
Rows
Personal
Business
Name
Address
Phone
Email
Broker/Investment Advisor
Rows
Personal
Business
Name
Address
Phone
Email
Banker/Trust Officer
Rows
Personal
Business
Name
Address
Phone
Email
Financial Planner
Rows
Personal
Business
Name
Address
Phone
Email
Insurance Agents (Life)
Rows
Personal
Business
Address
Phone
Email
Insurance Agents (Life)
Rows
Personal
Business
Address
Phone
Email
Insurance Agents (Property/Casualty)
Rows
Personal
Business
Address
Phone
Email
Other Key Relationships
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Business Snapshot
Business Form
C Corp.
S Corp.
LLC
LP
Other
If "Other," what form?
Ownership/Distributions
Rows
Name
Business Form
Your Ownership %
Estimated Value
Do you have a Buy-Sell agreement?
Business 1
Yes
No
Business 2
Yes
No
Business 3
Yes
No
Business 4
Yes
No
Business 5
Yes
No
Business 6
Yes
No
Business 7
Yes
No
Please send us income statements and balance sheets if available.
Notes
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Trust 1 Fact Sheet
Trust 1 Name
Date of Trust
-
Month
-
Day
Year
Date
Tax ID
Type of Trust
Grantor
Rows
Beneficiary Name
Relationship
SS#
%
1
2
3
4
5
6
7
Trust 1 Purpose
Other Notes
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Trust 2 Fact Sheet
Trust 2 Name
Date of Trust
-
Month
-
Day
Year
Date
Tax ID
Type of Trust
Grantor
Rows
Beneficiary Name
Relationship
SS#
%
1
2
3
4
5
6
7
Trust 2 Purpose
Other Notes
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Trust 3 Fact Sheet
Trust 3 Name
Date of Trust
-
Month
-
Day
Year
Date
Tax ID
Type of Trust
Grantor
Rows
Beneficiary Name
Relationship
SS#
%
1
2
3
4
5
6
7
Trust 3 Purpose
Other Notes
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Preliminary Planning
The Planning Process
1. Why are you interested in reviewing your life insurance program?
2. What specifically about your current situation causes concern?
3. What aspects of your program need improvement in your opinion?
4. What are your high-level visions and goals?
5. How would you describe yourself in terms of risk tolerance?
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Preliminary Planning
Planning Objectives
What are your debts, obligations and passions and what do you believe they will be in 10 years?
Rows
Debts (Now)
Debts (10 Years)
Mortgage #1
Mortgage #2
Mortgage #3
Credit Cards
College Loans
401(k)/IRA Loans
Other Loans
Cosigned Loans
Business Loans
Divorce Requirements
Other
Obligations - Aging Parents
Obligations - Special Needs Children
Obligations - Care for Siblings
Obligations - Other
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Personal Passions - Church, other activities
Personal Passions - Special Legacy Bequests
Personal Passions - Care for Siblings
Personal Passions - Other Charities
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Please describe the income you wish to provide:
Before Tax
After Tax
Beneficiary
Rows
How Much?
How Long?
Spouse
Children
Grandchildren
Parents
Siblings
Other
What specific assets do you want to protect from liquidation?
Preliminary Planning
Other Specific Legacy Wishes
Legacy Wishes - Family
Legacy Wishes - Business
Legacy Wishes - Charities
Legacy Wishes - Other
Notes
Submit
Should be Empty: