Annuity Discovery Questionnaire
Answer a few questions to help us understand your financial picture before we discuss whether an annuity—or a change to one—may fit your needs.
Your Information
Full Name
*
First Name
Middle Name
Last Name
Co-Client / Spouse Name
First Name
Middle Name
Last Name
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Section 1 - Personal & Household Profile
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Co-Client/Spouse Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
State of Residence
Marital Status
Please Select
Single
Married
Widowed
Divorced
Household health and longevity considerations
Section 2 - Income & Cash Flow
Total Annual Household Income ($)
*
Estimated Monthly Living Expenses ($)
*
Sources of Income
*
Social Security
Pension
Employment/Wages
Investment Income
Rental Income
Other
Section 3 - Financial Standing
Liquid Net Worth ($)
*
Total Net Worth ($)
*
Qualified Retirement Accounts IRA/401k ($)
*
Real Estate Equity ($)
*
Life Insurance Cash Value ($)
*
Total Outstanding Liabilities/Debts ($)
*
Section 4 - Liquidity & Time Horizon
Liquid reserves staying outside this annuity / emergency fund ($)
*
Anticipated need for these funds in the next 1-5 years
*
None anticipated
Possible
Likely
Overall time horizon for these funds
Section 5 - Goals & Risk Tolerance
Primary objective for this annuity
*
Principal protection
Guaranteed lifetime income
Growth potential
Legacy/wealth transfer
Long-term care funding
Other
Risk tolerance
*
Conservative
Moderate
Growth-oriented
When must guaranteed income begin if applicable
Section 6 - Funding Source
Source of funds
*
1035 exchange from existing annuity/life policy
CDs/Savings
Brokerage/Investment account
Qualified retirement account
Other
Account type
*
Qualified
Non-Qualified
Section 7 - Your Existing Contract
Current carrier / contract type
Approximate years remaining in surrender
Current accumulation / cash value ($)
Known annual fees, if any
Active riders (income or death benefit)
Section 8 - Advisor Notes & Client Acknowledgment
Anything else we should know
I confirm that the information provided above is accurate to the best of my knowledge and reflects my current financial situation, needs, and objectives. I understand this questionnaire is a discovery tool and does not represent a product recommendation.
I confirm the information above is accurate to the best of my knowledge
*
I confirm the information above is accurate to the best of my knowledge
Client Signature
*
Co-Client/Spouse Signature
Submit
Submit
Should be Empty: