Carriers Capsur Homepage Support Agent Portal Target Markets Case Design Training Forms Fact-Finders Client Intake Form Client Intake Form 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! Individual Policy Performance Review Homeowner's Quote Homeowner's Quote Agency Name * Effective Date of Policy * MM DD YYYY Prior Carrier * Named Insured * Property Location * Address 1 Address 2 City State/Province Zip/Postal Code Country Current Carrier Premium * $ Has the insured had 12 months of continuous coverage? * Yes No If no above, date policy was canceled: MM DD YYYY Dwelling Value * $ Liability Limit * $ Med Pay Limit * $ Protection Class * Year Built * Square Footage * Dwelling Updates (Year) Construction Frame & Deductible * Fire Extinguishers? * Yes No Dead Bolts? * Yes No Smoke Detectors? * Yes No Central Heat? * Yes No Central Alarm? Yes No Local Alarm? * Yes No Insured DOB * MM DD YYYY SS# Occupation? * Swimming Pool or Trampoline? * Which one, if pool is fenced? Swimming Pool Trampoline Both Dog & Breed * Any losses in the 3 years? * Any special endorsements? Is Auto currently written by your agency? * Yes No Mortgage Info Thank you! Group Health Questionnaire Group Health Questionnaire I. Company and Current Enrollment Information Company Name * Business Description Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Benefits Contact Name * Benefits Contact Email * Benefits Contact Phone # * (###) ### #### Total # Employees on Payroll * Total # Full-Time * Total # Part-Time * Number of Business Locations * Please Identify All States of Operation * Are you currently with a PEO * Yes No If yes, name of PEO? Current Health Carrier * Years with Current Carrier? * Total # of Employees Enrolled? * Health Carrier Renewal Date? * MM DD YYYY Renewal Rates Received? * Yes No Is Claims Experience available for your group? * Yes No Is your Current Plan Self‐Funded? * Yes No Any COBRA participants that will be on the health plan as of the proposed effective date? Please provide the following information for your Eligible COBRA Participants: II. Current Health Plan Employer Contribution Information Current Health Plan Employer Contribution Information * (If your Company has more than one Contribution Level, please list each separately) III. General Questions Please answer the following questions on behalf of your Company to the best of your knowledge. Has anyone been treated for a disability, serious illness, been hospitalized or had surgery in the past 5 years? * If yes, please provide details in the table (Section IV) below Yes No Is anyone currently hospitalized, confined at home, confined in a treatment facility, and/or incapable of self‐support because of physical or mental disability? * If yes, please provide details in the table (Section IV) below Yes No Is anyone currently being treated or been advised to seek treatment for any of the following: * Check ALL that apply (please provide details in the table (Section IV) below for any boxes checked): AIDS or testing HIV Positive arthritis back disorder cancer kidney disorder liver disease muscular disorder nervous system disorder stroke transplant(s) tumor heart disease substance dependency mental illness respiratory disease diabetes other IV. For ALL boxes checked YES, please provide details below Details: Is anyone currently pregnant? * Yes No Thank you! Annuity Proposal Request Annuity Proposal Request Agent * First Name Last Name Date MM DD YYYY Phone (###) ### #### Email * Carrier / Annuity Product * Policy Type * SPIA Deferred Variable Indexed Gender * Male Female Other Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Deposit Amount * $ Qualified or Non-Qualified? Qualified Non-Qualified Thank you! Agent Proposal Request Business Retirement 65+ Legacy Legacy Planning Forms
