Legacy Assurance Plan Customer Intake

Legacy Assurance Plan Customer Intake

Please complete this form to help us better understand your estate planning needs. Feel free to reach me directly at 816-277-9800 cbrown@legacyassuranceplan.com
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Demographics
Date of Birth*

MonthDayYear
Date
Marital Status

SingleMarriedDivorcedWidowedOther
Family / Beneficiary Information
Family Members / Beneficiaries
Current Estate Planning Documents
Which estate planning documents do you currently have?

WillTrustPower of AttorneyAdvance Healthcare DirectiveNoneOther
Would you like assistance updating or creating any estate planning documents?

YesNo
Insurance / Policies
What types of insurance or policies do you currently have?

Life InsuranceLong-Term Care InsuranceAnnuitiesNoneOther
Would you like to discuss insurance or policy options?

YesNo
Financial Overview
Estimated Total Assets
Estimated Total Liabilities
Are you on Medicaid?

YesNo
Goals & Concerns
What are your primary estate planning goals and concerns?
How much are you willing to spend to take care of this?
Do you have a mortgage?

YesNo
If NO do you have a TOD on your home?

YesNo
Other than your primary home, do you own any other real estate?
Membership & Referral Information
How did you hear about Legacy Assurance Plan?
If referred, please provide the name of the person or organization.
Should be Empty:

Legacy Assurance Plan Customer Intake

Demographics

Family / Beneficiary Information

Current Estate Planning Documents

Insurance / Policies

Financial Overview

Goals & Concerns

Membership & Referral Information