Client Profile Client Profile Step 1 of 12 8% Client 1 Name(Required) First Last Client 2 Name First Last Marital Status— Please Select One —MarriedSingleDivorcedWidowedNumber of ChildrenPlease select "Add Entry" to add children Child’s Name DOB Phone Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Former Spouse’s Date of Birth MM slash DD slash YYYY Notes Client 1Legal Name Date of Brith MM slash DD slash YYYY AgeBirthplace Mobile PhoneOther PhoneEmail Address Primary Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How long have you been there? Secondary/Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Client 2Legal Name Date of Brith MM slash DD slash YYYY AgeBirthplace Mobile PhoneOther PhoneEmail Address Primary Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How long have you been there? Secondary/Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Notes SOURCES OF INCOME Client 1Client 2Are You Employed?— Please Select One —YesNoAre You Employed?— Please Select One —YesNoEmployer Employer Years at EmployerYears at EmployerHave You Retired?— Please Select One —YesNoHave You Retired?— Please Select One —YesNoPlanned Retirement Age Planned Retirement Age Years RetiredYears RetiredCurrent/Former Occupation Current/Former Occupation Salary MonthlySalary MonthlySocial SecuritySocial SecurityPensionPension% of Pension to Spouse% of Pension to SpouseInvestmentsInvestmentsOtherOtherInvestment DetailsInvestment DetailsRMDRMDTotal Monthly IncomeTotal Monthly IncomeMonthly Household IncomeAnnual Household IncomeMonthly Household Living ExpensesNotesEconomic Impact of Losing a Spouse EDUCATIONAL PRIORITIES Please rate the following priorities by their level of importance to you. This will help us to determine which areas to focus our education on. 1 = Strongly Disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly Agree Client 1Client 2Knowing that my spouse will be financially secure if they survive me12345Knowing that my spouse will be financially secure if they survive me12345Leaving a financial legacy to my heirs12345Leaving a financial legacy to my heirs12345Reducing risk within my portfolio12345Reducing risk within my portfolio12345Reducing the amount of capital gains taxes I currently pay or will pay in retirement12345Reducing the amount of capital gains taxes I currently pay or will pay in retirement12345Reducing the amount of income taxes I currently pay or will pay in retirement12345Reducing the amount of income taxes I currently pay or will pay in retirement12345Morally, legally and ethically disinheriting the IRS12345Morally, legally and ethically disinheriting the IRS12345Leaving money to my favorite charity12345Leaving money to my favorite charity12345Generating additional income12345Generating additional income12345Protecting my assets from lawsuits12345Protecting my assets from lawsuits12345Protecting my estate from the cost of LTC12345Protecting my estate from the cost of LTC12345I would like to make sure my Medicare plan is best for me12345I would like to make sure my Medicare plan is best for me12345Would you like to learn how to make your home a tax-free asset?12345Would you like to learn how to make your home a tax-free asset?12345Client 1 Signature Date MM slash DD slash YYYY Client 2 Signature Date MM slash DD slash YYYY ASSETS Please provide asset information including cash and cash equivalents, annuities, stocks, bonds, mutual funds, etc. Client 1Please select "Add Entry" to add assets Company Type Tax Status Balance Contributing Contributing Amount Surr/Pen Surr/Pen Amount Income Income Amount Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. HiddenBalance TotalHiddenContributing TotalHiddenSurr/Pen TotalHiddenIncome TotalClient 2Please select "Add Entry" to add assets Company Type Tax Status Balance Contributing Contributing Amount Surr/Pen Surr/Pen Amount Income Income Amount Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. HiddenBalance TotalHiddenContributing TotalHiddenSurr/Pen TotalHiddenIncome Total GUARANTEED/FUTURE INCOME - Social Security Client 1Client 2Full Retirement AgeMonthly AmountFull Retirement AgeMonthly AmountGUARANTEED/FUTURE INCOME - PENSION Client 1Client 2Election AgeElection AgeMonthly AmountMonthly AmountPercentage to Spouse— Please Select One —25%50%75%100%Percentage to Spouse— Please Select One —25%50%75%100%Lump-Sum Buyout Lump-Sum Buyout Other LIABILITIES Please provide liability information, including mortgages, auto loans, credit cards, etc. Please select "Add Entry" to add mortgages Mortgage Original Balance Current Balance Current Value APR % Monthly Payment Extra Payments Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Client 1Please select "Add Entry" to add other liabilities Name Type Original Balance Current Balance APR % Monthly Payment Extra Payments Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Client 2Please select "Add Entry" to add other liabilites Name Type Original Balance Current Balance APR % Monthly Payment Extra Payments Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. HEALTH Client 1Client 2Do you smoke?— Please Select One —YesNoDo you smoke?— Please Select One —YesNoIf You Quit, How Long Ago? If You Quit, How Long Ago? Which of the following health conditions have you had in the last 10 years? Cancer Major Surgery Diabetes Type 1 Diabetes Type 2 Other None Which of the following health conditions have you had in the last 10 years? Cancer Major Surgery Diabetes Type 1 Diabetes Type 2 Other None NotesNotesESTATE Client 1Client 2Do You Have a Will?— Please Select One —YesNoDo You Have a Will?— Please Select One —YesNoDo You Have a Trust?— Please Select One —YesNoDo You Have a Trust?— Please Select One —YesNoTrust Name Executor/Successor Trustee Date of Trust MM slash DD slash YYYY Do You Anticipate An Inheritance?— Please Select One —YesNoDo You Anticipate An Inheritance?— Please Select One —YesNoApproximate AmountApproximate AmountWhen Anticipated When Anticipated From Whom From Whom Notes RISK MANAGEMENT Life Insurance Client 1Please select "Add Entry" to add Life Insurance Insurance Company Policy Type Policy Number Policy Owner Death Benefit Monthly Payment Cash Value Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Client 2Please select "Add Entry" to add Life Insurance Insurance Company Policy Type Policy Number Policy Owner Death Benefit Monthly Payment Cash Value Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. NotesMEDICARE COVERAGE Client 1Client 2Company Company Supp. Or MA— Please Select One —Supp.MASupp. Or MA— Please Select One —Supp.MAMonthly PaymentMonthly PaymentBasic Benefits— Please Select One —YesNoBasic Benefits— Please Select One —YesNoPreventative Services— Please Select One —YesNoPreventative Services— Please Select One —YesNoPart A Deduction— Please Select One —YesNoPart A Deduction— Please Select One —YesNoPart B Deduction— Please Select One —YesNoPart B Deduction— Please Select One —YesNoPart B Excess Charges— Please Select One —YesNoPart B Excess Charges— Please Select One —YesNoLONG-TERM CARE INSURANCE Client 1Client 2Company Company Policy Type Policy Type Year Purchased Year Purchased Elimination Period Elimination Period Daily BenefitDaily BenefitBenefit Term Benefit Term Inflation Rider Inflation Rider Return of Premium Return of Premium Death BenefitDeath Benefit BENEFICIARIES Client 1Primary Secondary Tertiary Client 2Primary Secondary Tertiary NotesCURRENT ADVISORS Client 1Client 2Tax Preparer Tax Preparer Phone NumberPhone NumberInsurance Advisor Insurance Advisor Phone NumberPhone NumberAttorney Attorney Phone NumberPhone NumberInvestment Advisor Investment Advisor Phone NumberPhone NumberNotes AREAS OF FOCUS Based on the priorities you’ve identified, we need to focus on:Notes ANNUITY ANALYSIS OWNER: BENEFICIARIES: Primary Annuitant: Contingent: Name of Company: Policy: Policy Fixed Variable Index Name of Annuity: Company Phone #:Date of Original Contract: MM slash DD slash YYYY Overnight Address: Qualified Qualified Non-Qualified If Qualified, Type? Total Premiums Paid to Date: Penalty-Free Amount Available: Current Accumulation Value: Withdrawal Provisions: Current Surrender Value: % Avail Per Year:Date Avail: MM slash DD slash YYYY % Surrender Charge Now:Next Year %:% Long-Term Care:Current MVA Value: % Home Health Care:Current Income Account Value: % Terminal Illness:Income per year if income started now: How is Death Benefit Paid: Total withdrawals to date: What is the cost basis: Contract driven by: Owner Annuitant Where did the funds come from: Minimum Guaranteed Value: For Index Annuity: Investment Strategies or Crediting Methods:IF A VARIABLE ANNUITY1M/E Expenses: Admin Expense: Average Fund Expenses: Any Riders? Yes No Fees for Existing Riders: Current Death Benefit: Amount Required to Stay in Policy to Retain Death Benefit: IF FIXED ANNUITYCurrent Interest Rate: Payable through when: Any Riders? Yes No Fees for Existing Riders: IF A FIXED INDEXED ANNUITYValue Last Calendar Year: Value Most Recent Anniversary: Any Riders? Yes No Fees for Existing Riders: NotesAgent of Record: Phone:Client Signature Date MM slash DD slash YYYY 1While it is important to consider all assets when accessing your current situation, I am not securities-registered and thus cannot provide any advice regarding your investments or variable annuities.NameThis field is for validation purposes and should be left unchanged. Δ
