Insurance Questionnaire

Please complete the following form as best you can.
Note, all information submitted in this form is highly confidential.

If you have any questions, please feel free
to call: 913-543-3836 or email: contact@wallastreet.com

Name

First NameLast Name

Email

example@example.com

Policy #1 Insured Name:

Policy #1 Owner Name:

Policy #1 Beneficiary Name:

Policy #1 Number:

Policy #1 Institution Name:

Policy #1 Purchase Date:

Date

Policy #1 Type:

(Whole life, VWL, Term, UL, VUL, Group, Other)

If Policy #1 is group life, does the term end at retirement?

YesNo

If Policy #1 is term life, how many years?

Policy #1 Current Death Benefit:

Policy #1 Current Cash Value:

Policy #1 Annual Premium:

Policy #2 Insured Name:

Policy #2 Owner Name:

Policy #2 Beneficiary Name:

Policy #2 Number:

Policy #2 Institution Name:

Policy #2 Purchase Date:

Date

Policy #2 Type:

(Whole life, VWL, Term, UL, VUL, Group, Other)

If Policy #2 is group life, does the term end at retirement?

YesNo

If Policy #2 is term life, how many years?

Policy #2 Current Death Benefit:

Policy #2 Current Cash Value:

Policy #2 Annual Premium:

Policy #3 Insured Name:

Policy #3 Owner Name:

Policy #3 Beneficiary Name:

Policy #3 Number:

Policy #3 Institution Name:

Policy #3 Purchase Date:

Date

Policy #3 Type:

(Whole life, VWL, Term, UL, VUL, Group, Other)

If Policy #3 is group life, does the term end at retirement?

YesNo

If Policy #3 is term life, how many years?

Policy #3 Current Death Benefit:

Policy #3 Current Cash Value:

Policy #3 Annual Premium:

Life Insurance Additional Details:

Insurance: Long Term Care

Long Term Care Insured Name:

Long Term Care Owner Name:

Long Term Care Policy Number:

Long Term Care Institution Name:

Long Term Care Purchase Date:

Date

Long Term Care Elimination Period:

(0, 20, 30, 40, 50, 60, 90, 100, 120, 180 days, 1 year)

Long Term Care Annual Premium:

Date

Long Term Care Premium Term (Years):

Long Term Care Benefit Amount:

Long Term Care Period for Benefit Amount:

(Annually, Quarterly, Monthly, Weekly, Daily)

Long Term Care Benefit Period:

(2, 3, 4, 5, 6, 7, 10 years, Lifetime)

Long Term Care COLA %:

(No Growth, Inflation, Custom)

Long Term Care COLA Type:

(Simple, Compound)

Long Term Care Simple COLA Base:

Long Term Care COLA Period (Years):

Insurance: Disability

Disability Insured Name:

Disability Owner Name:

Disability Policy Number:

Disability Institution Name:

Disability Policy Type:

(Group Short Term, Group Long Term, Personal Short Term, Personal Long Term, Other)

Disability Purchase Date:

Date

Disability Term Ends at Retirement?:

YesNo

Disability Elimination Period:

(0, 7, 14, 30, 60, 90, 180 days, 1 year, 2 years)

Is disability policy for Own Occupation?:

YesNo

Disability Annual Premium:

Disability Premium Term (Years):

Disability Benefit Type:

(Fixed Amount, Percent of Salary)

Disability Benefit Amount:

Disability Period for Benefit Amount:

(Annually, Quarterly, Monthly, Weekly, Daily)

Disability Benefit Percent:

Disability Maximum Initial Benefit Cap:

Disability Maximum Annual Benefit:

Disability Benefit Period:

(90, 180 days, # of years, Age, Life)

Disability COLA:

(No Growth, Inflation, Custom)

Disability COLA Type:

(Simple, Compound)

Disability Simple Cola Base:

Reduce by Social Security disability?

YesNo

Insurance: Property/Casualty

Property/Casualty Institution Name:

Property/Casualty Policy Type:

(Auto, Homeowners, Umbrella, Flood, Rental, Condo, Boat, Other)

Property/Casualty Policy Number:

Property/Casualty Annual Premium:

Property/Casualty Indexed at:

(No Growth, Inflation, etc.)

Type a question

Property/Casualty Premium Term (Years):

Property/Casualty Insured Asset:

Insurance: Medical

Medical Institution Name:

Medical Group Health Plan Sponsor:

Medical Policy Number:

Medical Policy Type:

(Primary, Other)

Medical Plan Type:

(Individual, Family)

Medical Deductible Amount:

Medical Annual Premium:

Medical Indexed at:

Type a question

(No Growth, Inflation, etc.)

Medical Premium Term (Years):

Additional General Insurance Notes: