|
Confidential
Questionnaire
|
Q
|
| Name |
|
| Address |
|
| City |
|
| State |
|
| Zip Code |
|
| Day Phone |
|
| Evening Phone |
|
| Email |
|
| Your Age |
|
| Spouse Name |
|
| Spouse Age |
|
| Your
Occupation |
|
| Income |
|
| Spouse Occupation |
|
| Spouse Income |
|
| Number of
Children |
|
| 1st
Marriage? |
|
| Do
You Have A Will? |
|
| Do
You Have Any Trusts? |
|
Your total assets
(select a range)
|
| $0
- $100,000 |
| $100,000
- $250,000 |
| $250,000
- $1,000,000 |
| $1,000,000
- $5,000,000 |
| over
$5,000,000 |
|
Your
total liabilities
(select a range)
|
| $0
- $100,000 |
| $100,000
- $250,000 |
| $250,000
- $1,000,000 |
| $1,000,000
- $5,000,000 |
| over
$5,000,000 |
|
| Do
you currently contribute a "Qualified Savings Plan"
(IRA, 401k, etc.) |
|
| If
so, how much do you contribute each year? (select a range) |
|
| Are
you currently covered by a "pension" plan at work? |
|
| Are
you eligible for stock options at work? |
|
| What
is the term of your home mortgage? (select one) |
|
| Do
you make extra payments or bi-weekly payments on your mortgage? |
|
| Total
amount of life insurance on your life? |
|
| Type
of insurance on your life? |
|
| Total
amount of life insurance on your spouse? |
|
| Type
of insurance on your spouse's life? |
|
| Have
you ever heard of the concept called "human life value"? |
|
| Do
you have long-term disability insurance? |
|
| Do
you have long-term care insurance? |
|
| Do
you, or any member of your household have serious or debilitating
health issues? |
|
| Do
you anticipate, or are about to receive, any inheritances and/or large
cash settlements? |
|
| Are
you planning to retire soon and/or do you have money which needs to be
moved from an existing 401k plan to a self-directed IRA? |
|
| What
are your monthly household expenses? |
|
| Select
any advisors who provide financial advise to you? |
|
| Additional
Comments |
|
| |
|
|