Vantage Client Questionnaire

Full Name *

EXISTING INSURANCE

Are you confident you have the right coverage at the best price? It’s very common that, as time goes on, the coverage you have is no long appropriate or the best pricing. Do you have a good relationship? Would you like a 2nd opinion?

Life Insurance

Insured Person #1

Policy #1 (Ins.1)

Full Name
Death Benefit
Premium
Term/Type
Cash Value?
Carrier

Policy #2 (Ins.1)

Full Name
Death Benefit
Premium
Term/Type
Cash Value?
Carrier

Policy #3 (Ins.1)

Full Name
Death Benefit
Premium
Term/Type
Cash Value?
Carrier

Policy #4 (Ins.1)

Full Name
Death Benefit
Premium
Term/Type
Cash Value?
Carrier

Insured Person #2

Policy #1 (Ins.2)

Full Name
Death Benefit
Premium
Term/Type
Cash Value?
Carrier

Policy #1 (Ins.2)

Full Name
Death Benefit
Premium
Term/Type
Cash Value?
Carrier

Policy #3 (Ins.2)

Type
Ins. Company
Premium
Term
Notes

Policy #4 (Ins.2)

Type
Ins. Company
Premium
Term
Notes

Other Existing Insurance Policies

(i.e. DI, LTC, Home Owners, Auto, etc.)

Policy #1 (Oth.)

Type
Ins. Company
Premium
Term
Benefit Amount
Notes

Policy #2 (Oth.)

Type
Ins. Company
Premium
Term
Benefit Amount
Notes

Policy #3 (Oth.)

Type
Ins. Company
Premium
Term
Benefit Amount
Notes

Policy #4 (Oth.)

Type
Ins. Company
Premium
Term
Benefit Amount
Notes

Full Name *

ABOUT

About You

Are you the only one(s) involved in making financial decisions?

Yes

Who else makes decisions?

Their relationship to you?

Do you have a financial advisor?

Yes

Who is your advisor?

Does he/she call you? When did you speak last?

Do you have regular reviews?

Yes

On a scale of 1 to 5, 5 being "perfect" and 1 being "unacceptable", how would you rate your current advisor?

In your perspective, does he/she have expertise or experience in retirement income planning, insurance, and all matters of financial planning, or is there a missing piece?

What are the things you like most about him/her?

What don’t you like or would change?

Would their input be required in the plans we make together, or do you make financial decisions independent of them?

I make independent financial decisions.

I require my advisor for decisions.

GOALS

Let’s imagine we have already decided to work together and we’ve just finished the initial steps. What would we need to accomplish for you to be able to say you are absolutely thrilled with the outcome?

Retirement age goal

Income goal at retirement

What are some of your other financial goals, urgent and immediate, as well as long term?

Short term goals:

Long term goals:

What are your goals as related to your children? College? First home? Weddings? Inheritance?

What about your parents? Do you anticipate needing to provide for them or take care of them?

Full Name *

ASSETS & INCOME

Do you have a Will or Trust in place?

Yes

When was it put in force?

When was it reviewed last?

Is this something important to you that you'd like to learn more about?

Occupation

Job Title (Yours)

Employer (Yours)

Years of service (Yours)

Current Base Salary (Yours)

Bonus Income (Yours)

Job Title (Spouse)

Employer (Spouse)

Years of service (Spouse)

Current Salary (Spouse)

Bonus Income (Spouse)

Real Estate

Your residence:

Estimated market value (Res)

Mortgage balance (Res)

Interest rate (Res)

Payment amount (Res)

Does payment include Taxes and Insurance? (Res)

Yes

Term length (Res)

Time remaining (Res)

Other Home:

Estimated market value (O.H.)

Mortgage balance (O.H.)

Interest rate (O.H.)

Payment amount (O.H.)

Does payment include Taxes and Insurance? (O.H.)

Yes

Term length (O.H.)

Time remaining (O.H.)

Other Real Estate:

Estimated market value (O.R.)

Mortgage balance (O.R.)

Interest rate (O.R.)

Payment amount (O.R.)

Does payment include Taxes and Insurance? (O.R.)

Yes

Term length (O.R.)

Time remaining (O.R.)

Notes

Real estate notes

Investments and Savings

Husband:

Account Balances Total Value [Husband]

Bank Accounts
MMA, CDs, Bonds
Traditional IRA
Roth IRA
401K / 403B / 457 / Pensions
Mutual Funds, Stocks, etc.
Other investments

Monthly Contribution [Husband]

Bank Accounts
MMA, CDs, Bonds
Traditional IRA
Roth IRA
401K / 403B / 457 / Pensions
Mutual Funds, Stocks, etc.
Other investments

Wife:

Account Balances Total Value [Wife]

Bank Accounts
MMA, CDs, Bonds:
Traditional IRA
Roth IRA
401K / 403B / 457 / Pensions
Mutual Funds Stocks, etc.
Other investments

Monthly Contribution [Wife]

Bank Accounts
MMA, CDs, Bonds
Traditional IRA
Roth IRA
401K / 403B / 457 / Pensions
Mutual Funds, Stocks, Etc.
Other Investments

Joint/Other:

Account Balances Total Value [Jnt/Oth]

Bank Accounts
MMA, CDs, Bonds
Traditional IRA
Roth IRA
401K / 403B / 457 / Pensions
Mutual Funds, Stocks, Etc.
Other Investments

Monthly Contribution [Jnt/Oth]

Bank Accounts
MMA, CDs, Bonds
Traditional IRA
Roth IRA
401K / 403B / 457 / Pensions
Mutual Funds, Stocks, ect.
Other Investments

Full Name *

DEBTS

DEBT #1

Debt Name
Balance
Payment (min)
Payment (actual)
Interest %
Term

DEBT #2

Debt Name
Balance
Payment (min)
Payment (actual)
Interest %
Term

DEBT #3

Debt Name
Balance
Payment (min)
Payment (actual)
Interest %
Term

DEBT #4

Debt Name
Balance
Payment (min)
Payment (actual)
Interest %
Term

DEBT #5

Debt Name
Balance
Payment (min)
Payment (actual)
Interest %
Term

DEBT #6

Debt Name
Balance
Payment (min)
Payment (actual)
Interest %
Term

DEBT #7

Debt Name
Balance
Payment (min)
Payment (actual)
Interest %
Term

DEBT #8

Debt Name
Balance
Payment (min)
Payment (actual)
Interest %
Term

DEBT #9

Debt Name
Balance
Payment (min)
Payment (actual)
Interest %
Term

DEBT #10

Debt Name
Balance
Payment (min)
Payment (actual)
Interest %
Term

Full Name *

HEALTH

In order to prepare accurate options and pricing, it’s very helpful if I know a little bit about your health. Would it be ok if I ask you some health questions?

“Field Underwriting”

[Husband] Height

[Wife] Height

[Husband] Weight

[Wife] Weight

[Husband] Tobacco, Marijuana, or Nicotine

Yes/No
Which of the above?
Frequency/When (if in past)
Dosage
Details

[Wife] Tobacco, Marijuana, Or Nicotine

Yes/No
Which of the above?
Frequency/When (if in past)
Dosage
Details

[Husband] Diabetes

Yes/No
Frequency/When (if in past)
Dosage
Details

[Wife] Diabetes

Yes/No
Frequency/When (if in past)
Dosage
Details

[Husband] Cancer

Yes/No
Frequency/When (if in past)
Dosage
Details

[Wife] Cancer

Yes/No
Frequency/When (if in past)
Dosage
Details

[Husband] Heart Condition

Yes/No
Frequency/When (if in past)
Dosage
Details

[Wife] Heart Condition

Yes/No
Frequency/When (if in past)
Dosage
Details

[Husband] High Blood Pressure

Yes/No
Frequency/When (if in past)
Dosage
Details

[Wife] High Blood Pressure

Yes/No
Frequency/When (if in past)
Dosage
Details

[Husband] High Cholesterol

Yes/No
Frequency/When (if in past)
Dosage
Details

[Wife] High Cholesterol

Yes/No
Frequency/When (if in past)
Dosage
Details

[Husband] Major Injuries

Yes/No
Frequency/When (if in past)
Dosage
Details

[Wife] Major Injuries

Yes/No
Frequency/When (if in past)
Dosage
Details

[Husband] Surgeries

Yes/No
Frequency/When (if in past)
Dosage
Details

[Wife] Surgeries

Yes/No
Frequency/When (if in past)
Dosage
Details

[Husband] Medications

Yes/No
Frequency/When (if in past)
Dosage
Details

[Wife] Medications

Yes/No
Frequency/When (if in past)
Dosage
Details

[Husband] Anxiety/Depression

Yes/No
Frequency/When (if in past)
Dosage
Details

[Wife] Anxiety/Depression

Yes/No
Frequency/When (if in past)
Dosage
Details

Any other health information?

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