What is your most important financial goal?

Most important personal goal?

What percentage of your income do you think you should be saving?

What is your desired retirement age?

What percentage of your current income do you want in retirement ?

Avg retiree need 70%-90%

What amount do you need to keep liquid in case of emergencies or opportunities

Liquid being available with 72hrs.

Foundations/Stage 1*

Net Worth

Liabilities + Assets

Liabilities

Assets

What desired MAP allocations do you want after learning our investment philosophy?

Wall Street Rule of Thumb

MAP Tax Allocations

Pre-Tax

After-Tax

Above the line

Below the line

What amount are you committed to saving, above and beyond what you are currently doing on a monthly basis?

The people you care about!

Gender

Male Female

Address

State

Zip code

Email

example@example.com

Phone

Area Code Phone Number

Best time to call

Social Security No.

Driver's License No.

Exp Date

No U.S. Other Country of citizenship: Is the Proposed Insured a U.S. citizen or U.S. resident alien taxpayer? Yes

Exp Date

Date

State

Other

U.S.

State of birth

How long living in the U.S.?

Since birth or

Street

City

Country

Zip code

Dependent's age(s)

No Have you used tobacco, nicotine, or any nicotine substitution in the last five years? Yes

to undergo diagnostic procedures or tests for any symptoms, illnesses, or conditions?

any hazardous activity?

This is not an application for life insurance. However, your answers to this confidential questionnaire may be used by your agent to assist you in applying for life insurance. Life insurance application is subject to underwriting. No insurance exists until and unless the application is approved and the premiums to put the policy in force have been paid.

Other life insurance coverage:

Company

Relationship

Name

Relationship

Bank information

Area Code Phone Number

Bank name

Router/Transit number

City, State

Note: Please list a "Contingent Beneficiary" (Back up beneficiary if something were to happen to you and beneficiaries together

(If Applicable) Primary Care Doctor: Date of last visit:

(If Applicable)

Primary Care Doctor

Reason/Diagnosis: Medication/Dose/Times per day:

Date of last visit

Date

Reason/Diagnosis

Medication/Dose/Times per day

(If Applicable) Current Medications:

(If Applicable)

Current Medications

Dose/Times per day

(If Applicable)List other doctors seen within last 5 years: Date:

Date

Reason/Diagnosis: Medication/Dose/Times per day: Date of recovery:

Reason/Diagnosis

Medication/Dose/Times per day

Date of recovery

New York Life Insurance Company 51 Madison Avenue New York, NY 10010 www.newyorklife.com

AR08632.082016 SMRU1714610 (Exp.11.04.2020)

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NEW YORK LIFE