New Client Intake Form Agent Who Assisted? * Please include the name of the agent who helped you. First Name Last Name Personal Information Your Name * First Name Last Name Spouse's Name First Name Last Name Your DOB * MM DD YYYY Spouse's DOB MM DD YYYY Your Email * Spouse's Email Your Height & Weight Spouse's Height & Weight Tobacco Use? No Yes Spouse Tobacco Use? No Yes Hazardous? * No Yes Spouse Hazardous? No Yes Emergency Contact for Financial Matters: * Children Children? Yes No Child 1 DOB MM DD YYYY Child 2 DOB MM DD YYYY Child 3 DOB MM DD YYYY Child 4 DOB MM DD YYYY Residence Information Residence Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Do you Own or Rent? Own Rent Monthly Mortgage / Rent Amount? * $ Mortgage Balance? If Applicable $ Professional Advisor Information Your Will - Date & Type? Spouse's Will - Date & Type? Financial Advisor's Name? First Name Last Name Employment / Income Information Your Occupation? * Spouse Occupation? Employer's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Employer's Phone * Country (###) ### #### Annual Income * Securely Stored $ Other Income? $ Financial Information Savings $ Investments $ IRA(s) $ Real Estate $ Business Interests $ Personal Property $ Other $ Total Assets $ Installment Loans $ Mortgage(s) $ Credit Card / Charge Accounts $ Business Debt $ Other Debts $ Total Liabilities $ Current Monthly Systematic Savings $ Insurance Information Life Insurance Life Insurance 2 Long-Term Care Insurance Other Insurance? Planning Priorities Survey Protecting Family's Lifestyle Strongly Disagree Disagree Neutral Agree Strongly Agree Protecting Income Strongly Disagree Disagree Neutral Agree Strongly Agree Providing Education Funds Strongly Disagree Disagree Neutral Agree Strongly Agree Implementing Savings Plan Strongly Disagree Disagree Neutral Agree Strongly Agree Planning for Retirement Strongly Disagree Disagree Neutral Agree Strongly Agree Minimizing Estate Shrinkage Strongly Disagree Disagree Neutral Agree Strongly Agree Planning for Business Continuation Strongly Disagree Disagree Neutral Agree Strongly Agree How much do you feel comfortable setting aside on a monthly basis? $ Thank you!
