ALPS Client Financial Intake Form

Client Financial Intake Form

Comprehensive inputs allow us to help our clients the most!
Privacy Notice: Your personal information is collected solely for the purpose of evaluating and providing life insurance and financial products tailored to your needs. All information provided will be kept strictly confidential and is used only for internal purposes to guide our recommendations. We do not share your information with third parties without your consent, except as required by law or to facilitate the services you request.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Protection
P1: Vehicle Insurance
Coverage Limits
Annual Premium
Deductible Amount(s)
P2: Property Insurance
Coverage Limits
Annual Premium Amount
Deductible Amount(s)
P3: Liability Insurance
Coverage Amount
Annual Premium Amount
P4: Disability Insurance
Monthly Benefit
Benefit Duration
Premium Amount
P5: Medical Insurance
Deductible
Annual Premium
P6: Government Plans
Annual Social Security Benefits
Medicare Coverage
P7: Wills & Documents
Executor Fees
Estate Value
P8: Trust & Owner
Trust Assets
P9: Life Insurance
Permanent Insurance Death Benefit
(If multiple policies, separate Face Amounts with a dash. For example: 500k - 1m - 100k)
Permanent Insurance Annual Premium
(If multiple policies, separate total annual premium amounts with a dash. For example: 12k- 24k - 3k)
Term Insurance Death Benefit & Term Duration
(If multiple term policies list in following manner: (Death Benefit Amount/term duration/convertible or non-convertible)

Savings
S1: Wealth Coordination Account/Checking Account
Account Balance
Fees
S2: Savings
Account Balance
Account Interest Rate
S3: Credit Union
Account Balance
Account Interest Rate
S4: Savings Bonds
Purchase Amount
Interest Rate
S5: Certificates of Deposits (CDs)
Current Value
Term Length
Interest Rate(s)
S6: Money Market Account (MMA)
Account Balance
Account Interest Rate
S7: Tax Deferred

401(k), Traditional IRA, SEP IRA, etc
Account Type and Account Value
Contribution Amount
Contribution Frequency
S8: Tax Free

Roth IRA, Health Savings Account (HSA), 529 College Savings Plans, etc
Account Type and Account Value
Contribution Amount
Contribution Frequency
S9: Tax Deductible

Roth IRA, Health Savings Account (HSA), 529 College Savings Plans, etc
Account Type and Account ValueS9: Tax Deductible
Contribution Amount
Contribution Frequency

Growth
G1: Government Bonds

Roth IRA, Health Savings Account (HSA), 529 College Savings Plans, etc
Maturity Period
Interest Rate
G2: Corporate Bonds

Roth IRA, Health Savings Account (HSA), 529 College Savings Plans, etc
Coupon Rate
Maturity Date
G3: Municipal Bonds

Roth IRA, Health Savings Account (HSA), 529 College Savings Plans, etc
Coupon Rate
Maturity Date
G4: Preferred Stocks

Roth IRA, Health Savings Account (HSA), 529 College Savings Plans, etc
Dividend Yield
Share Quantity & Price
G5: Blue Chip Stocks

Roth IRA, Health Savings Account (HSA), 529 College Savings Plans, etc
Dividend Yield
Share Quantity & Price
G6: Growth Securities

Roth IRA, Health Savings Account (HSA), 529 College Savings Plans, etc
Sector
G7: Collectibles
Items and Appraised Value
G8: Real Estate
Rentals, Value, and Remaining Mortgage
Rental Income (Monthly/Annually)
G9: Businesses/Shelters
Type and Ownership Stake
Business Valuation
Financial Disclaimer: This intake form is designed for information-gathering purposes only and does not constitute a financial or insurance recommendation. Any advice provided will be based on the information you supply. Please note that financial outcomes may vary based on individual circumstances, and it is recommended to consult with a licensed professional for specific guidance. Policy terms, tax treatment, and benefits are subject to applicable laws and regulations and may change over time.
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Client Financial Intake Form