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Untapped Financial Strategies
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Have questions, please call (312) 600-4849 // or email tiffani@untappedfinancialstrategies.com
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What are your current needs & what would you like to discuss?
(Select all that are appropriate)
*
Annuities - so that you do not outlive current or future retirement income
All things financial - Unsure where to start
Budgeting (review or/and tools)
Business: Buy Sell Agreements
Business: Key Person Insurance or Executive Bonus Plans
College Funding Education (Alternatives to 529 Plans)
Financial Literacy Session or Workshop (all ages and organizations)
Life Insurance (Cash Value, Term, Whole Life, Index Universal or Guaranteed Life, Final Expense)
Qualified Retirement Plans
Referrals for Estate Planning Attorney, CPA, Realtor or Debt Consolidation
Rollover of former employer retirement plan
Supplemental Retirement Plans (planning for future income)
Wealth Transfer Planning
Other:
Required
Financial Literacy Session or Workshop Request
Please select proposed date
MM
/
DD
/
YYYY
Financial Literacy Session or Workshop Details:
1) Audience (Who will attend & age range)
2) Your organization/institution with contact name & #
3) Expected # of people
4) Goal of session
5) Select preferred date above, then list alternative dates for session below
6) Duration for session
Your answer
Life Insurance & Annuity Needs
Your answer
1)
First & Last Name of person to be insured
2) Date of birth
2) Social Security #
(If preferred, can be provided during consultation)
For multiple people, please state name next to each
*
Your answer
Full Residential Address (including city, state, zip code)
*
Your answer
Born in what City, State, & Country
*
Your answer
Do you have a valid & current Driver's License
OR
State ID?
*
Choose
Yes
No
1) Driver's License or State ID Number
2) Expiration Date
3) List if Expired or Suspended (as of what date)
If for multiple people, please state name next to each
*
Your answer
Height & Weight
If for multiple people, please state name next to each
*
Your answer
Email address for policy information
*
Your answer
Best contact number with area code
*
Your answer
IF insurance policy is for child (Adult or Trust could be owner) -
1) First & last name of parent
2) Parent date of birth
3) Parent Social Security #
4) OR Trust name and when it was created
*
Your answer
Is this for business (key person) or individual life insurance?
Choose
Individual
Business
Do you need assistance with budgeting for self or business?
Your answer
Employer Name & Address
OR
Are you Self Employed
OR
Retired?
*
Your answer
1) Years of Employment
2) Annual income (W2/Self Employed or Retired)
3) How many years before you retire/change career
*
Your answer
Current insurance policies
(Name of company & Amount)
Is it term or whole life insurance?
If none, please put N/A
OR
Will this replace a prior policy
(past 6 months) then list company name and policy #
*
Your answer
Please list company name, amount of:
1) Existing annuities?
2) Current amount in retirement accounts
(include Roth or Traditional IRAs, TSP, 401k, 457, 403b)
*
Your answer
Have you ever been declined for life insurance?
OR
Declined for an annuity?
*
No
Yes
Would you like a consult to determine how much insurance you need?
OR
Do you already know insurance coverage amount desired?
*
Your answer
Monthly premium (range) or budget amount ($)
*
Your answer
Date for premium withdrawal (1st - 27th)
*
Your answer
Beneficiaries for your policy
List at least 1 primary and 1 back up person/entity, state their relationship to you & date of birth i.e. (01-01-2001)
OR name of Entities or Charities
Total must equal 100%
*
Your answer
Medical Section - *If for an annuity put "N/A"
1) Physician Name
2) Address
3) Phone Number
*
Your answer
Medical Section -
1) Last date seen by Physician
2) Any follow-up needed
*
Your answer
Medical Section -
1) Any medical conditions or diagnosis
(i.e. high blood pressure, diabetic or others)
2) Hospitalizations in past 10 years
(please list year and reason)
*
Your answer
Medical Section -
Prescriptions:
1) List each and (year started if remembered)
2) Dosage prescribed
3) Physician who prescribed
*
Your answer
Family History -
History of any illnesses
(which family member, medical diagnosis & their age of onset)
*
Your answer
Family History -
Parents still alive, if known, for one or both parents (current age)
*
Your answer
Family History -
Parent(s) if deceased (cause of death & their age)
*
Your answer
Banking Information -
Name of Institution
*
Your answer
Banking Information -
Routing Number
(Can be provided during call)
Your answer
Banking Information -
Account Number (Can be provided during call)
Your answer
Who else would you like us to talk with about
Life Insurance, Financial Planning, Wealth Transfer, or Retirement Options?
Name & contact information
(Please do an introduction for us OR let them know someone from Untapped Financial Strategies will contact them)
Your answer
Would you like a referral for CPA, Estate Attorney (Trust) or Business Bookkeeping?
Your answer
End of Form:
Do you have any questions?
Thank you for allowing us to serve you!
Your answer
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