Case Design Request Form

Case Design Request Form
Agent's Full Name*
ex. John Smith
Agent's Email*
example@example.com
Your Company*
Put In Your Client's Information Below:
Name Of Owner Of Qualified Funds:*
Premium Amount*
(Numbers Only - Enter The Full Number, Ex. 500000 instead of 500k)
What Cash Bonus %?*
*CHECK THE STATE YOUR CLIENT IS IN AND THEIR AGE FOR BONUS VARIATIONS* We will try and catch errors, but please do your due diligence.
Assumed Rate of Return*
Show RMD's being taken?*
Use net RMD's to offset taxes owed from policy?*
If client doesn't need RMDs for income, this will use the RMD distribution, net of taxes, to help pay for the taxes owed on the conversion amount, allowing more money to be converted into Roth funds.
Calculate Taxes?*
Taxes will be calculated, but not subtracted to show client the estimated taxes owed.
Subtract Taxes?*
THE "CALCULATE TAXES?" DROPDOWN HAS TO BE YES IF THIS IS ALSO SELECTED AS YES.
Age Of Owner*
(Numbers Only)
Birth Date Of Owner

MonthDayYear
(OPTIONAL)
Choose Which Carrier: *
Estimated Effective Income Tax Percentage:*
Be sure to account for state taxes if the client's state has them. Be realistic with your tax assumptions. Example: A $1,000,000 premium being converted isn't going to be a 12% tax rate.
Marital Status:*
Age Of Spouse:
(OPTIONAL)
Estimated Age Of Death Of Owner:
(OPTIONAL)
Estimated Age of Death For Spouse:
(OPTIONAL)
State Residence:*
When Is Your Next Meeting With This Client?*

MonthDayYear
Date
NOTES (Type any additional notes; if none type 'N/A')*
Should be Empty:

Case Design Request Form

Put In Your Client's Information Below: