Valoram Intake Form -- Annuity

CLIENT INFORMATION FORM

Congratulations on your decision to stay one step ahead today! Please fill out the information below to proceed with your Annuity application.
POLICY OWNER INFORMATION
Name*

First NameLast Name
Gender*

MaleFemale
Phone Number

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Social Security #*
Place of Birth*
Town/City
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Civil Status*
Occupation*
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Annual Salary*
Source of Funds*

SalaryBenefits from Maturing PolicyOther
Is the Proposed Insured the same as the Policy Owner?*

YesNo
Driver's License #
Expiration Date
STATE
Insurance Information

Any Life insurance in place?
Any Life Insurance in Place
DUI's, speeding violations, reckless driving, suspended license in past 5 years?
Any Felonies/Misdeameanors/ Bankruptcies
Surrending Company Policy
Surrendering Company Policy:
Surrendering Company Name

Surrending Company Account

Surrender Amount

Product Type (IRA/ROTH/NQ/401k/Pension Lump-Sum)
Information on Beneficiaries
Beneficiary Name

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Place of Birth*
Town/City, Province
Mobile Number*

xxxxxx-xxxx
Email Address*
example@example.com
Home Address

No/Flr, Bldg, Street Name

Subdivision, Barangay

CityState / Province

Postal / Zip Code
Relationship to the insured*
Allocation:*
Out of 100%
Suitability Information
Household Total Income
Approx Monthly Household Expenses
Liquid Holdings ; Stocks & Bonds :
Mutual Funds:
Annuities (PF):
Cash/MMkts/CDs:
Checking & Savings:
Retirement Plan (>59.5)
TOTAL LIQ ASSETS:
Mutal Funds- B/C shares
Retirement Plans Under 59.5
Approx Value of Home:
Life Insurance CV:
Annuities in Surrender Period:
Other:
TOTAL NON-LIQ Holdings:
Please upload a copy of your valid ID here

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Misc Notes:
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CLIENT INFORMATION FORM

POLICY OWNER INFORMATION

Insurance Information

Information on Beneficiaries

Suitability Information