Financial Questionnaire

1
Marital Status* This field is required.
Single
Married
2
Legal Name* This field is required.
First Name
Middle Name
Last Name
3
Date of Birth* This field is required.
Birthdate
Month
Day
Year
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Email* This field is required.
example@example.com
6
Phone Number* This field is required.
Please enter a valid phone number.
7
Estimated Net Worth* This field is required.
< $250,000
$1,000,000 - $5,000,000
$250,000 - $1,000,000
> $5,000,000
8
Estimated Annual Gross Income* This field is required.
< $100,000
$250,000 - $1,000,000
$100,000 - $250,000
> $1,000,000
9
Spouse's Legal Name* This field is required.
First Name
Middle Name
Last Name
10
Spouse's Date of Birth* This field is required.
Birthdate
Month
Day
Year
11
Spouse's Email* This field is required.
example@example.com
12
Spouse's Phone Number* This field is required.
Please enter a valid phone number.
13
Estimated Household Liquid Net Worth* This field is required.
< $250,000
$1,000,000 - $5,000,000
$250,000 - $1,000,000
> $5,000,000
14
Estimated Household Annual Gross Income* This field is required.
< $100,000
$250,000 - $1,000,000
$100,000 - $250,000
> $1,000,000
15
Do you have children?* This field is required.
YESNO
16
Please list your children's First & Last Name and Date Of Birth.* This field is required.
17
How did you hear about us?* This field is required.
Google/Search Engine
Facebook
YouTube
Blog
Referral
18
Who referred you?* This field is required.
19
Paint a picture of what your ideal life looks like in 5 - 10 years.* This field is required.How are you spending your time? Who are you spending it with? What emotions are you feeling? Are you traveling? What hobbies are you enjoying? What organizations are you volunteering for?
20
What would you like to accomplish that will require PLANNING, MONEY, and TIME?* This field is required.Common Answers: Paying Off Debt, College Savings, Retirement Savings, Travel, Buying A Business, Home Improvements, Leaving A Legacy
21
What are three non-financial goals in your life right now?* This field is required.Examples: Run A Marathon, Declutter Home, Read Two Books Every Month, Maintain A Healthy Work-Life Balance, Practice Daily Gratitude, Master A Difficult Skill, Learn To Speak A Foreign Language, Drink Enough Water Everyday, Learn To Play A Musical Instrument
Goal # 1
Goal # 2
Goal # 3
22
How do you feel about your current financial situation? List your feeling(s) then describe what makes you feel that way.* This field is required.Common Feelings: Secure, Peace, Stability, Stress, Anxiety, Sleeplessness, Worry, Comfortable, Grateful, Content, Frustrated, Optimistic, Regret, Sense of Remorse, Stuck, Lack of Motivation/Action, Envy, Inadequate, Resentful, Hopelessness, Despair
23
What actions are you taking to ensure the achievement of your goals?* This field is required.Common Answers: Set Clear Goals, Create A Budget, Reduce Expenses, Increase Income, Save & Invest, Pay Off Debt, Build An Emergency Fund, Automate Savings, Seek Financial Education, Review & Adjust, Seek Professional Advice, Stay Motivated
24
What are your biggest concerns or potential roadblocks?* This field is required.Check All That Apply.
Not Enough Time
Lack Of Financial Literacy
No Desire To Manage My Finances
Creating & Sticking To A Budget / Making Wise Spending & Saving Decisions
Debt Burdened - Credit Cards, Student Loans, High Interest Rates, Monthly Payments
Lack Of Emergency Fund
Self / Spouse Dying Early & Losing Ability To Maintain Style Of Living
Current Or Potential Health Issues
Job Security / Income Stability
Lack Of Liquidity In Savings
Paying For Kids' Education
Not Saving Enough For Retirement
Suffering Investment Losses
No Plan For Retirement Income
Paying Too Much In Taxes
Inflation / Rising Costs Of Living
Out Living Money
Costs Of Healthcare / Long-Term Care Expenses
Financial Scams Or Frauds
Ensuring Proper Distribution Of Assets After Death & Protection Of Loved Ones
Family Needs Financial Help
25
What's your philosophy on debt?* This field is required.
I hate being in debt to anyone.
I am ok with carrying a small amount of debt.
I am ok with carrying a large load of debt as long as I am using it for the right reasons.
26
What's your philosophy on taxes?* This field is required.
I am happy to pay my fair share of taxes every year.
I don't like paying income taxes but understand I must, so I have developed a tax strategy to make sure I am paying the least amount possible every year. I would rather pay some tax today than pay more income tax later in life.
I hate paying taxes and do everything I can to avoid paying any type of taxes every year. I would rather avoid paying taxes today and take my chance on paying more taxes later in life.
27
What's your philosophy on insurance?* This field is required.
I am interested in spending the least amount of premium for bare minimum coverages.
I am ok paying premium as long as I know my assets and family are protected.
I tend to over-insure as I do not like the idea of having to spend money out of my pocket when something bad happens.
28
How do you feel about investing in the stock market?* This field is required.
I think the market will lose 30% of its value at least once in the next five years.
I think the market will break even over the next five years with lots of volatility.
I think the market will continue to go up in the next five years as it has historically.
29
What do you want from your investments?* This field is required.
I don't want to lose money, even if that means lower or no gains.
I want income now. I am ok with a little up and down in investment, but not too much.
I want income now and some potential for growth. I am ok with short-term volatility.
I don't need money soon. I am looking for growth, so some volatility is ok.
I am looking for maximum growth in the long-run. I expect volatility.
30
When working with a financial advisor what's most important to you?* This field is required.Check All That Apply.
Helps me stay in control of my emotions
Has a good reputation and positive reviews
Is knowledgeable on tax consequences of investing
Can help me maximize my returns
Is approachable and easy to talk to
Helps me reach my financial goals
Is easy to get a hold of
Has a clear fee structure so I know what I am paying for
Understands me and my unique needs
Uses up-to-date technology
Acts as a coach / mentor to keep me on track
Presents themselves in a professional manner
Keeps my interests in focus with unbiased advice
Communicates and explains financial concepts well
Has the relevant skills and knowledge
31
Why do you feel you would be a great client of Johnson Insurance?* This field is required.
Should be Empty: