Client Interest Questionnaire

Client Interest Questionnaire
Name*
Date*

MonthDayYear
Date
Email*
example@example.com
Contact Number*
1. What are you looking to achieve by working with us?*
2. Which of our services are you interested in? (Select all that apply)*

Wealth Building & PlanningCreating Generational Wealth through Life InsuranceReal Estate FundingBusiness Startup Formation & DevelopmentBusiness Credit & Business FundingBusiness Marketing ServicesBusiness Management ServicesBusiness Financial Management
3. Do you own a business ?*

YESNO
Name of Business : *
# of years owning the business : *
What services does the business provide ? *
4. Please list any of the following that you currently have in place:
Life Insurance:

TermPermanent
StocksBondsReal Estate InvestmentsIf Other Investment vehicles, please list:
Business Insurance Coverage ( Select All That Apply)

Business Owner’s InsuranceProfessional Liability InsuranceBusiness Property InsuranceKey Person Life InsuranceSplit Dollar Life InsuranceBuy-sell Agreement CoverageGroup Life Insurance
Retirement Investment Accounts:

IRA401KOther
5. Do you presently have a Personal Wealth Empowerment (Financial) Plan?*

YESNO
6. How soon are you looking to get started?*

NowWithin 1-2 weeks2 weeks - monthOther
Should be Empty: