Fintech Insurance Financial Questionnaire

A Strategy That Fits YOUR Situation

We provide this valuable, confidential service at no cost to our clients.
Let's dive into straightforward strategies that can help shape your financial future. We'll look at how to manage your money smarter—from boosting cash flow and tackling debt, to saving for the unexpected, protecting your income and assets, growing your wealth, and securing your family's financial legacy. These practical steps are designed to fit your life and goals, helping you build financial strength without the complexity.
Which Strategies Would You Like to Explore? (Select All That Apply)

Cash FlowDebt ManagementEmergency FundTax ReductionProper ProtectionAsset AccumulationEstate Preservation
What Agent Are You Working With?

Basic Client Information
Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Sex
Are you married?

NoYes
Spouse's Name

First NameLast Name
Spouse's Email
example@example.com
Spouse's Phone Number
Please enter a valid phone number.
Does Your Spouse Share the Same Address?

NoYes
Spouse's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Date of Birth

MonthDayYear
Date
Spouse's Sex
Do you have any children?

NoYes

Personal & Family Goals
Retirement Targets
What Age Would You Like To Retire?
Income Per Year in Retirement
Additional Questions
When you pay taxes do you usually pay or receive?

Pay the IRSReceive a Return
Average You Pay or Receive Each Year?
Tax / 12

Client Health Information
Do You Regularly Smoke or Vape?

NoCannabisTobaccoVape
List Any Medication(s) You Take Regularly
Do You Have Any Health Concerns?
Does Your SPOUSE Regularly Smoke or Vape?

NoCannabisTobaccoVape
List Any Medication(s) Your SPOUSE Take Regularly
Does Your SPOUSE Have Any Health Concerns?

Assets & Liabilities
Assets Combined Value(s)
Checking Account(s)
Saving Account(s)
Taxable Asset(s)
401k
IRA
Roth IRA
Roth IRA
Other Investment Accounts
Tax-Exempt Asset(s)
Home Equity
Home & R/E Asset(s)
Upload Supporting Asset Statements

Cancelof
Total Assets
Liabilities Combined Value(s)

Use the Total Due
Car Loan(s)
Credit Card(s)
Student Loan(s)
Home & R/E Loan(s)
Primary Home Mortgage
Current Mortgage Interest Rate
Personal Loan(s)
Other Loan(s)
Total Liabilities
Net Worth
Any Investment Properties?
Yes/ No
Number of Investment Properties?

Current Life Insurance(s)
Do you have any current Life Insurance Policies?

NoYes
Upload Statement / Policy

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Anything We Missed?

We hope this was comprehensive as it will guide us to create the perfect strategy to ensure that you are able to accomplish all of your goals!
Additional Notes
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