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In The Last 12 Months Have You Used Any Tabaco Products Including Vaping?
Currently Taking Prescription Medication To Stop Smoking?
Have you PERSONALLY EVER been diagnosed by a medical professional as having Cancer?
What about your spouse or significant other?
What MEDICAL CONDITION are you currently "prescribed" medication for? Even if you are not currently taking it.
Have you had any hospitalization or surgeries in the last 5 years? If so what was the procedure or treatment and about what time frame did it occur?
Do you have any criminal record of a misdemeanor or felony? If so what was the offense?
What about your spouse or significant other?
Have you ever had your drivers license suspended or revoked or have you ever had a DUI, DWI or convicted of driving while under the influence of narcotics? If so how many times?
when did it happen and what were the "convicted charges" that were filed against you?
What about your spouse or significant other?
Do you own any life insurance NOT including anything through work? (FYI -Some people have?
I don't have any life insurance at all
Do you have insurance through your work?
Term
I own this type of insurance
Term
Whole Life
IUL or UL
Variable Universal Life
I think I have something ,but not sure what it is.
How Often Do You Pay?
Please Select
Monthly
Quarterly
Bi-annually
Yearly
What Is The Death Benefit $_______________
Do You Have Any Cash Value If It Is A Permanent Policy
Please Select
Yes
No
How Much Cash Value? (type Zero) if none.
What is the death benefit $_____________?
List All Polices That You Currently Have
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Gross Annual Earned Income For Your Career Last Year
Gross Annual Earned Before Last Year?
Gross Annual Income Earned By Spouse
Gross Annual Earned Before Last Year?
ADDITIONAL MONTHLY INCOME FOR YOU/SPOUSE/SIGNIFICANT OTHER
2nd Job $_____________
Social Security $__________
Pension $__________
Investment Income $__________
Rental Income Income $__________
Child Support $__________
Other Income $__________
What Major Changes Do You Expect In Your Income In The Next Few Years?
Where Are You Currently Putting Your Money On A Monthly Basis
Ira
Roth
401k
403B
457
Savings Account
Stash Under Matress
Whos Account Is The One You Put Money Into
Please Select
Mine
Spouse
Children
What is the monthly balance in the account?
DEBT INFORMATION
Currently I Rent/Have Mortgage/No Mortgage
Please Select
Rent
Have Mortgage
No Mortgage
Current Monthly Mortgage Payment?(Principle & Interest Only Subtract any escrow or taxes/insurance.
Current Monthly Mortgage Balance?
Approximate Years Remaining
Current Interest Rate
Fixed Term Type
Please Select
30 Years
15 Years
Other Term
Adjustable Rate Mortgage
Please Select
Arm Mortgage 5 Year
Arm Mortgage 7 Year
Arm Mortgage 10 Year
Arm Mortgage Other
Do You Have A Second Mortgage On Another Property?
Please Select
Yes
No
Please List In Detail All Debts And Amounts Even With Zero Interest ( Do not include monthly bills such as phone/utilities etc.
List All Debts Including Interest Rates (in dollar ammounts)
Do you pay PMI - Primary Mortgage Insurance as part of your premium? Depending on how much you put down, which usually if you finance over 80% of the property. If you put less than 20% down then ask your lender or look on your monthly statement. Y / N If so how much?
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LAST AND FINAL SECTION
Current Resident Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How Many Years At Current Residence
Please Select
1
2
3
4
5
6
7
8
9+
How Many Children Do You Have?
Please Select
0
1
2
3
4
5
6
7
8
9
List Name and Dob Of All Children
Who else MIGHT you name as a beneficiary now of in the future? Title/Relationship to you.
What Is The Name And Address Of Your Doctor
What Is The Name And Address Of Your Doctor
When was your most recent visit?
Reason for visit and what was the outcome ex (annual check up?)
Were you prescribed any medications or treatments
Please Select
Yes
No
What was the medical treatment or prescription?
What is the name of the medication, dosage and frequency.For example- High blood pressure, Lisinopril, 5mg twice a day.
What is your desired total household retirement income? $_________
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