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New Clients

New Client Intake - Optional Information

Thanks for scheduling! The following information is optional, but if you’re ready to move forward, providing financial and personal information helps us to give you the best solution. All client data is kept strictly confidential.

"*" indicates required fields

1Client Details

2Cash Flows

3Balance Sheet

4Schedule a Consultation

Primary Client Details

Legal Name*

First Middle Last

Sex*

Male

Female

Date of Birth*

MM slash DD slash YYYY

Primary Residence*

Street Address Address Line 2 City State ZIP Code

Best Phone Number*

Email*

Marital Status*

Single, Never Married

Unmarried, In a Relationship

Married

Divorced

Widowed

Widower

Do you have children?*

Yes

No

Children Details

Legal Name*

First Middle Last

Sex*

Male

Female

Date of Birth*

MM slash DD slash YYYY

If you have more children then click on "Add Child" button

Do you have grandchildren?*

Yes

No

Grandchildren Details

Legal Name*

First Middle Last

Sex*

Male

Female

Date of Birth*

MM slash DD slash YYYY

If you have more grandchild then click on "Add Grandchild" button

Are you the insured person on any term insurance?*

Yes

No

This question is about term insurance only. You will have an opportunity to enter information regarding any permanent insurance on the Balance Sheet page.

Please only enter information regarding temporary term insurance where you are the insured person in this section.
Permanent insurance (e.g. whole life, universal life) is an asset, so you will have an opportunity to enter permanent insurance information on a later page in this form.

Policy Owner*

Self

Spouse

Employer

Other

Carrier*

This is the company that issued the policy.

Policy Number*

Issue Date*

MM slash DD slash YYYY

This is the date that the policy went in force.

Duration*

Death Benefit*

What was the original purpose for this policy?*

e.g. to cover final expenses, to protect my family, etc.

If you have more term policy then click on "Add Term Policy" button

Cash Flows

What kind of income do you collect?

I earn a salary from one or more employers.

I earn an hourly wage from one or more employers.

I'm paid as an independent contractor.

I'm a business owner and I take dividend draws/distributions.

I'm an investor. I collect capital gains.

I'm paid a pension from a former employer.

I take distributions from a tax-qualified retirement plan.

I collect Social Security.

I don't have any incoming cash flow.

Employment Income

Independent Contractor Income

What kind of work do you do?*

For how many years have you done this work?*

You can use a decimal to express fractions of a year.

Who are your customers?*

Do you work from home?*

Yes

No

Your Business Address*

Address Line 1 Address Line 2 City State ZIP Code

How much do you expect to earn this year?*

How much did you earn in the most recent, full calendar year (last year)?*

How much did you earn in the previous full calendar year (year before last)?*

Notes (Optional)

Please provide any other information that you feel is important regarding this entry.

Business Income

Investment Income

What kind of investing do you do?

For how many years have you been investing?

You can use a decimal to express fractions of a year.

How much do you expect to receive in capital gains this year?*

How much did you receive in capital gains in the most recent, full calendar year (last year)?*

How much did you receive in capital gains in the previous, full calendar year (year before last)?*

Notes (Optional)

Please provide any other information that you feel is important regarding this entry.

Pension Income

Tax-Qualified Plan Distributions

Social Security Income

How much do you expect to receive this year in Social Security payments?*

How much did you receive in Social Security payments in the most recent, full calendar year (last year)?*

How much did you receive in Social Security payments in the previous, full calendar year (year before last)?*

Notes (Optional)

Please provide any other information that you feel is important regarding this entry.

Total Incoming Cash Flows:

This Year

Price: $0.00

Last Year

Price: $0.00

Year Before Last

Price: $0.00

Balance Sheet

Assets

Add Item

Total Assets (excluding insurance):

Price: $0.00

Do you (or your spouse, if you're married) own any permanent life insurance?*

Yes

No

Permanent life insurance includes whole life, universal life, variable life, and indexed universal life.

Policy Details

Do you have any debt?

Yes

No

Liabilities

Total Liabilities:

Price: $0.00

Capital

Net Worth (excluding insurance)

Price: $0.00

Net Worth (including insurance)

Price: $0.00

Basic Underwriting Questions

Have you filed for bankruptcy within the last 10 years?*

Yes

No

Discharge Date*

MM slash DD slash YYYY

Have you ever consumed nicotine?*

Yes

No

When did you last consume nicotine?*

More than 10 years ago

5-10 years ago

1-4 years ago

Within the past year

I currently consume nicotine

In What Form?*

Cigarettes

Cigars

Chewing tobacco

A pipe

Lozenges/Pills

A patch

Vaping

Other

Other*

How frequently do you smoke cigars?*

Less than 12 in a year

Other

Have you ever consumed cannabis (marijuana)?*

Yes

No

When did you last consume cannabis?*

More than 10 years ago

5-10 years ago

1-4 years ago

Within the past year

I currently consume cannabis

In what form?*

Joint

Pipe/Bubbler

Bong

Other

Other*

Please explain approximately how much you consume (consumed).*

Do you have a Primary Care Physician (PCP)?*

Yes

No

Do you recall the contact information for the last Primary Care Physician you saw?*

Yes

No

Prior PCP Name*

First Last

Prior PCP Address*

Street Address Address Line 2 City State ZIP Code

Prior PCP Phone*

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Atlanta, GA
678-201-1629

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