BH Capital - Wealth Questionnaire

1
Name* This field is required.
First Name
Last Name
2
Birthdate* This field is required.
Date
Month
Day
Year
3
Gender* This field is required.
Male
Female
4
Marital Status* This field is required.
Single
Married
5
Number of Dependents* This field is required.
6
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Phone Number* This field is required.
Please enter a valid phone number.
8
Email* This field is required.
example@example.com
9
Occupation* This field is required.
10
Business Legal name/Employer's Name* This field is required.
11
Annual Income* This field is required.
12
Is your income expected to increase, decrease, or remain stable over the next 5 years?* This field is required.
Increase
Decrease
Remain Stable
13
Do you have any additional sources of income?* This field is required.
Yes
No
14
Additional Income Source(s)* This field is required.
Huge
Large
Normal
Small
Ok
Ok
15
Annual Amount from Additional Sources* This field is required.
16
Do you currently have any life insurance?* This field is required.
Yes
No
17
Type of Policy
Term
Whole Life
Universal Life
18
Coverage Amount* This field is required.Coverage Amount is the total amount an insurance policy will pay to beneficiaries or for claims, such as the death benefit in life insurance. It represents the level of financial protection provided by the policy.
19
Annual Premium* This field is required.Annual Premium is the total amount you pay once a year to maintain your insurance coverage. It ensures your policy remains active and can vary based on factors like coverage amount and policy type.
20
Insurance Company* This field is required.
21
Would you like to review or change your current policy?* This field is required.
Yes
No
22
What are your primary financial goals? (Select all that apply)* This field is required.
Retirement Planning
Estate Planning
Education Funding
Debt Protection
Other
23
How do you feel about taking risks with your investments?* This field is required.
Conservative
Moderate
Aggressive
24
What is your expected time horizon for achieving your financial goals?* This field is required.
0-5 Years
6-10 Years
11-20 Years
20+ Years
25
Do you have any specific investment preferences? (e.g., stocks, bonds, real estate)* This field is required.
Huge
Large
Normal
Small
Ok
Ok
26
How do you anticipate your financial needs changing over time?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
27
Are you a business owner?* This field is required.
Yes
No
28
Business Name* This field is required.
29
Industry* This field is required.
30
Years in Business* This field is required.
31
Annual Gross Revenue* This field is required.
32
Do you have key person insurance for your business?* This field is required.
Yes
No
33
Are there any partners in your business?* This field is required.
Yes
No
34
How many partners?
35
Do you have a buy-sell agreement in place?* This field is required.
Yes
No
36
Would you like to explore key person insurance options for your business?* This field is required.
Yes
No
37
What are your current monthly expenses?* This field is required.
38
Do you have any significant debts? (e.g., mortgage, loans)* This field is required.
Yes
No
39
Total Debt Amount* This field is required.
40
Monthly Debt Payments* This field is required.
41
What is your current savings or emergency fund?* This field is required.
42
What is your desired retirement age?* This field is required.
43
Do you have any existing retirement accounts?* This field is required.
Yes
No
44
Type of Retirement Account(s)* This field is required.
401(k)
IRA
Roth IRA
Other (Please Specify)
45
Total Amount in Retirement Accounts* This field is required.
46
What is your desired Life Insurance coverage amount?* This field is required.The question "What is your desired coverage amount?" asks how much money you want your life insurance policy to provide to your beneficiaries. This amount should cover things like debts, income replacement, and future expenses to ensure your loved ones are financially secure.
47
What duration of coverage are you seeking?* This field is required.
10 Years
20 Years
30 Years
Lifetime
48
Are you interested in adding any of the following riders? (Select all that apply)* This field is required.See Rider Definitions: Life Insurance Riders
Waiver of Premium
Accidental Death
Long -Term Care
Critical Illness
Disability Income
Child Term
Spousal Rider
Return of Premium
I'm not sure
Other
49
Health-Related Riders: (Select all that apply)* This field is required.See Rider Definitions: Life Insurance Riders
Accelerated Benefits Rider (ABR) - Alzheimer's Disease
Accelerated Benefits Rider - Chronic Illness
Accelerated Benefits Rider - Critical Illness or Critical Injury
Accelerated Benefits Rider - Terminal Illness
Waiver of Premium
Waiver of Monthly Deductions Rider
I'm not sure
50
Income and Wealth Protection Riders:(Select all that apply)* This field is required.See Rider Definitions: Life Insurance Riders
Lifetime Income Benefit Rider
Overloan Protection Rider
Premium Deposit Account
I'm not sure
51
Family and Survivor Protection Riders:(Select all that apply)* This field is required.See Rider Definitions: Life Insurance Riders
Children's Term Rider
Survivor Protection Rider
Death Benefit Protection Rider (DBPR)
Estate Preservation Rider
Policy Split Option Rider (PSO)
I'm not sure
52
Flexibility and Future Planning Riders:(Select all that apply)* This field is required.See Rider Definitions: Life Insurance Riders
Guaranteed Insurability Rider (GIR)
Exchange to a New Insured Rider (ENIR)
Additional Paid Up Life Insurance Rider
Systematic Allocation Rider
Flex Term Rider
I'm not sure
53
Distribution and Financial Management Riders:(Select all that apply)* This field is required.See Rider Definitions: Life Insurance Riders
Benefit Distribution Option (BDO)
Balance Sheet Benefit (BSB)
I'm not sure
Other
54
Would you like to include a cash value component in your policy?* This field is required.A cash value component in a life insurance policy allows part of your premiums to accumulate as a savings or investment over time. This cash value grows on a tax-deferred basis and can be accessed through loans or withdrawals during your lifetime. It provides an added financial resource, offering flexibility for emergencies, retirement income, or other needs, in addition to the policy's death benefit. Including a cash value component is often available in whole life, universal life, or other permanent life insurance policies.
Yes
No
55
Are there any specific goals you want your life insurance to achieve? (e.g., replace income, cover estate taxes, fund a business transfer)* This field is required.
Huge
Large
Normal
Small
Ok
Ok
56
Are you interested in annuities as part of your retirement planning?* This field is required.Annuities are financial products that provide a steady stream of income during retirement, typically for life or a set period of time. They are designed to help ensure you don’t outlive your savings. Annuities can be funded with a lump sum or through multiple payments and offer tax-deferred growth. They are often used to complement other retirement savings, such as 401(k)s or IRAs, providing guaranteed income to cover essential expenses and giving you greater financial security in retirement.
Yes
No
I'm not sure
57
What type of annuity interests you the most?* This field is required.The question "What type of annuity interests you the most?" is asking the user to choose between different types of annuities. Here’s a brief description of each option for clarity: Fixed: Provides a guaranteed interest rate and consistent payments during retirement. Variable: Allows investment in various sub-accounts, and payments fluctuate based on investment performance. Indexed: Tied to a market index (like the S&P 500), offering potential for growth while providing some level of protection against losses. Immediate: Begins making payments right after a lump-sum investment, usually used for immediate retirement income. Deferred: Delays payments until a future date, allowing the investment to grow over time before disbursing income.
Fixed
Variable
Indexed
Immediate
Deferred
58
What is your expected monthly retirement income need?* This field is required.
59
When do you plan to start receiving annuity payments?* This field is required.
Immediately
5 Years
10 Years
Other
60
Would you prefer annuity payments to last for a specific period or your lifetime?* This field is required.
Specific Period
Lifetime
61
Do you have any pre-existing health conditions?* This field is required.
Yes
No
62
Condition(s)* This field is required.
Huge
Large
Normal
Small
Ok
Ok
63
Do you use tobacco products?* This field is required.
Yes
No
64
What is your current height and weight?* This field is required.
65
Is there anything else you would like us to consider when evaluating your life insurance needs?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
66
When are you available for a Zoom meeting to discuss your options?* This field is required.
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67
Disclosure Acknowledgement* This field is required.By submitting this form, you acknowledge that BH Capital Funding, through its authorized representative Daniel Speiss, operates as a licensed insurance broker. BH Capital Funding may receive compensation from insurance carriers for products sold, including life insurance and annuities, which are offered in partnership with National Life Group and other carriers. Any recommendations provided through this needs analysis are based on the information you have provided and are intended to align with your stated financial goals and insurance needs.
68
Consent to Receive Information* This field is required.I consent to receive communications from BH Capital Funding and Daniel Speiss regarding life insurance and annuities, including but not limited to product information, policy reviews, and other financial services. I understand that these communications may be sent via email, phone, or other electronic means.
69
Compliance Acknowledgement* This field is required.BH Capital Funding and Daniel Speiss are fully compliant with the guidelines and regulations set forth by National Life Group and other insurance carriers represented. All recommendations and policy offerings adhere to ethical and legal standards to ensure that your financial and insurance needs are met in a transparent and fiduciary manner. National Life Group is not responsible for any tax, legal, or investment advice provided through this form or its affiliated parties. By signing below, I acknowledge that I have read and understood the above disclosures and consent to proceed with the insurance needs analysis provided by BH Capital Funding and Daniel Speiss.
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