Financial Needs Analysis Questionnaire
Thank you for taking the time to complete this form. Your answers will help us understand your financial priorities and create a plan tailored to your needs.
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Civil Status
*
Single
Married
Widowed
Separated
Number of Dependents
*
Age of youngest child / dependent
*
if none put n/a
Occupation
*
Monthly Income
*
AREAS OF FINANCIAL PLANNING
Let's asses your financial priorities.
1. PROTECTION (Income & Family Security)
Goal: Ensure your loved ones are financially secure in case of life’s uncertainties.
1. Do you currently have life insurance coverage?
*
YES
NO
If YES, how much is your current coverage?
*
if non put 0
2. Main Priority
*
Family Expenses
Pay Debts
Education
2. HEALTH and CRITICAL ILLNESS
Goal: Protect yourself and your family against unexpected medical costs.
HMO
*
YES
NO
If YES, how much is your coverage?
*
CRITICAL ILLNESS COVERAGE
*
YES
NO
If YES, how much is your coverage?
*
if none put 0
WHICH CONCERNS YOU THE MOST?
*
Hospital expenses
Long term treatment costs
Income Loss
3. SAVINGS and INVESTMENTS
Goal: Grow your money for short- and long-term goals.
Monthly Savings/Investment
*
YES
NO
If YES, how much have you saved?
*
TOP GOAL
*
Emergency Fund
Education
House
Business
Investment Style
*
Conservative (secure, low risk)
Balanced (moderate growth, some risk)
Aggressive (higher growth, higher risk)
4. RETIREMENT & ESTATE PLANNING
Goal: Secure your future lifestyle and protect your legacy.
1. Target retirement age:
*
2. Desired monthly income upon retirement:
*
Priority
*
Retire Early
Leave Legacy
PRIORITY RANKING Rank in order (1 = highest, 4 = lowest)
*
Rows
RANK
PROTECTION
1
2
3
4
HEALTH
1
2
3
4
SAVINGS & INVESTMENT
1
2
3
4
RETIREMENT & ESTATE
1
2
3
4
Appointment
*
Submit
Should be Empty: