Intake Form

We believe the two essential elements towards achieving financial independence are focusing on what matters, and what we can control. Providing a 3-dimensional panoramic view of their financial picture gives our clients the peace of mind to live purposeful and fulfilling lives, enabling them to pass the torch to the next generation as good stewards of the family legacy.

Step 1 of 12 - Intake Form Start

How will you be using this form

Insurance

Investments

Financial Planning

Who is your Advisor

Insurance Choices

Life

Disability

Long Term Care

Supplement for Business Policy

Joint Long Term Care

Investment Account Type

Individual Account

Joint Account

UTMA/UGMA Account

Trust Account

Traditional IRA, Rollover IRA, Roth IRA Account

Inherited IRA Account

SEP-IRA Account

SIMPLE IRA Account

529 Account

Individual Transfer on Death Account

Joint Tenant Transfer on Death Account

Corporate Account

Company Retirement Account: Solo 401(k), Profit Sharing, DB Pension Plan Account

Personal Information

First Middle Last

Mobile Phone

DOB

Month

Day

Year

Gender

Male

Female

Type of Citizenship

Resident US Citizen

Non-resident US Citizen

Resident Alien

State of Birth

Country of Birth

Social Security Number

Driver's License Identification Number

Driver's License State/Province of Issue

Driver's License Issue Date

Month

Day

Year

Driver's License Expiration Date

Month

Day

Year

Residential Address

Street Address Address Line 2 City State / Province ZIP Code

Is the Mailing Address the same as the Residential Address

Yes

Mailing Address

Street Address Address Line 2 City State / Province ZIP Code

Marital Status

Spouse Name

First Middle Last

Spouse Mobile Phone

Spouse Email

Spouse DOB

Month

Day

Year

Spouse Gender

Male

Female

US Citizen (Spouse)

Yes

Spouse Type of Citizenship

Resident US Citizen

Non-resident US Citizen

Resident Alien

Spouse State of Birth

Spouse Country of Birth if not a U.S. Citizen

Spouse Social Security Number

Spouse Driver's License Identification Number

Spouse Driver's License State/Province of Issue

Spouse Driver's License Issue Date

Month

Day

Year

Spouse Driver's License Expiration Date

Month

Day

Year

Is the Spouse Mailing Address the same as the Residential Address

Yes

Spouse Mailing Address

Street Address Address Line 2 City State / Province ZIP Code

Dependents

Yes

Please specify Dependents

Name

Employment Status

The Business is a

Business Name

Title

Business Address

Street Address Address Line 2 City State / Province ZIP Code

Company Website

Business Owner Phone

Ownership of Policy (provide exact Business name or indicate same as above)

Beneficiary of Policy (provide exact Business name or indicate same as above)

Signer for the business shoud be

Business Tax ID Number

Company Address

Street Address Address Line 2 City State / Province ZIP Code

Industry

Year Established

# of Employees

Type of Organization

Sole Proprietorship

Partnership

LLC/LLP

Corporation

S Corp

Non Profit

Company Book Value

a. Total Assets

b. Total Liabilities

c. Total Net Worth

Company Market Value

a. Market Value

b. Insured percentage of Ownership

Please enter a number from 0 to 100.

c. Date of last format variation

Month

Day

Year

Company Net Profit Before Taxes

a. Current Year

b. Last Year

List other currently insured Stockholders, Partners or Key Persons

1. Name

First Last

1. Title

1. Percentage Owned

Please enter a number from 0 to 100.

1. Insurance in Force (Dollars)

1. Insurance Applied For (Dollars)

2. Name

First Last

2. Title

2. Percentage Owned

Please enter a number from 0 to 100.

2. Insurance in Force (Dollars)

2. Insurance Applied For (Dollars)

3. Name

First Last

3. Title

3. Percentage Owned

Please enter a number from 0 to 100.

3. Insurance in Force (Dollars)

3. Insurance Applied For (Dollars)

4. Name

First Last

4. Title

4. Percentage Owned

Please enter a number from 0 to 100.

4. Insurance in Force (Dollars)

4. Insurance Applied For (Dollars)

Total Must Equal 100

Total Percentage Owned for Insured Stockholders, Partners or Key Persons

Does the business carry life insurance on the lives of business officer(s) or partner(s)

Yes

Purpose of Insurance (Select all that apply)

Key employee (List special skills, knowledge or abilities possessed in Additional Details)

Stock redemption/Cross purchase

Loan guarantee coverage

Deferred Compensation

Other

Is there a written agreement

Yes

Provide the date the agreement originated

Month

Day

Year

Name of Lender

Purpose of Loan

Amount of Loan

Date of Loan

Month

Day

Year

Years of Loan

Additional Details: Indicate section letter and question number.

INV - Are you or an immediate family member associated with or employed by a stock exchange or member firm of an exchange or FINRA, or a municipal securities broker-dealer

Yes

Enter company name and trading symbol

Financials

Income

Current Tax Year Income

Previous Tax Year Income

Current Year Investment Income

Current Year Rental Income

Combined Annual Income

Please enter a number greater than or equal to 0.

Physical Activity

State Proposed Insured works in

How long has the proposed insured been employed with his or her current employer?

How many hours per week, on average, does the Proposed Insured work in his or her occupation?

For the last 90 days, have you been continuously at work for your usual and customary manner, performing all of the duties of your occupation without limitation due to injury or sickness?

Yes

Assets & Liabilities

Banking & Investments

Description

Institution

Type

Ownership

Value

Business Interests

Business Name

Industry/Description

Entity Type

Ownership %

Current Valuation

Buy/Sell Agreement in Place?

Real Estate Holdings

Property Name

Property Type

Ownership Type

Ownership %

Current Market Value

Net Cash Flow

Liabilities

Property Name

Mortgage Balance

Mortgage Lender

Interest Rate

Maturity Date

Monthly Payment

Personal Guarantees

Entity Guaranteed

Creditor/Lender Name

Type of Obligation

Amount Guaranteed

Term/Duration

Collateral/Security

Health & Lifestyle

Determined disabled by a medical professional, or applied for disability benefits

Yes

Details

Used tobacco/nicotine products (except cigars) in the last 12 months (cigarettes, e-cigs/vape, pipes, snuff, chew, gum/patch)

Yes

Details

Used cigars in the last 24 months

Yes

How many

1-24

25+

Used prescription meds for smoking cessation/substitution (e.g., Chantix, Wellbutrin) in the last 12 months

Yes

Details

Felony conviction ever, or currently on parole/probation

Yes

Details

DUI/DWI (alcohol or drugs) in the last 5 years

Yes

Details

At-fault motor vehicle accident in the last 3 years

Yes

If yes, provide details

Speeding tickets < 15 mph over

Yes

Speeding tickets > 15 mph over

Yes

Details

License suspended

Yes

When suspended

Month

Day

Year

Reinstated

Yes

Details

Military: plan to become or be a member of active/inactive reserves or National Guard in the next 2 years

Yes

Details

Pilot / student pilot / aircrew in the last 3 years or plan to be in the next 2 years

Yes

Details

Hazardous activities (underwater diving, hang gliding, parasailing/kiting, parachuting/skydiving, ultralight, soaring, ballooning, bungee, rock/mountain climbing, heli-skiing, organized racing—auto/motorcycle/motorboat/snowmobile) in the last 3 years or intend in the next 2 years

Yes

Details

Plan to travel or reside outside the U.S. in the next 2 years

Yes

Details

Height

Weight

Primary Doctor

Phone

Address

Street Address Address Line 2 City State / Province ZIP Code

Last Visit Date

Month

Day

Year

Reason for Visit

List All Medications in the last 2 years

List the medication name, the prescribing physician name and the dosage/frequency of use.

Pre-Existing Health Conditions

Age of Mother

Age of Father

Parents Health History

PROTECTION

Life Insurance

Carrier

Policy #

Face Amount

Type

Owner

Beneficiary

Disability Income Protection

Carrier

Policy #

Type

Monthly Benefit

Benefit Period

Elimination Period

Personal Lines Insurance

Carrier

Policy #

Type

Liability Limit

Uninsured/Underinsured

Is this a replacement of coverage from another Carrier

Yes

Replacement Carrier Name

Owner Name

First Last

Policy Owner

Owner Phone

Owner Social Security #

Owner DOB

MM slash DD slash YYYY

Owner Address

Street Address Address Line 2 City State / Province ZIP Code

Trust Name

Trust Tax ID

Trust Creation Date

Month

Day

Year

INFORCE LIFE INSURANCE (OWNER):

Provide the total life insurance currently applied for or now in force

Name

Relationship

Age

Coverage Amount

Group Coverage

How long have you lived at your current address

Hazardous sports/activities in the last 3 years

Foreign travel last year or the next two years (Specify location and dates)

Tickets/accidents in the last 5 years

Yes

Have you ever been declined or rated by another company

Yes

If yes, provide details

Declining Company Name

Reason for decline or rating

Decline Date

Month

Day

Year

Protection

Last Will & Testament

Yes

Year Last Updated

Durable Power of Attorney

Yes

Year Last Updated

Revocable Living Trust

Yes

Year Last Updated

Health Care Proxy / Living Will

Yes

Year Last Updated

Where are originals stored?

Fiduciaries

List

Name

Type

Specialized Roles

Trust Protector

Has limited powers to oversee/modify a trust (optional, used in advanced plans)

Conservator

Court-appointed guardian of property for an adult (if needed)

Charitable Trustee / Foundation Board

If there’s a private foundation or charitable trust

Charitable Gifting

List

Benefactor

Recipient

Gift Amount

Vehicle

Gift Frequency

Timing

Taxes & Protection

Estimated Estate Value vs. Estate Tax Exemption

Approximate Estate Value

Lifetime Gift Exemption Used

Life Insurance Ownership (individual vs. trust/ILIT)

Existing Asset Protection Structures (LLCs, FLPs, SLATs, etc.)

Special Concerns

Heirs with special needs or creditor concerns

Yes

Heirs with special needs or creditor concerns

Blended family / children from prior marriage

Yes

Blended family / children from prior marriage

Desire to protect assets from divorce or lawsuits

Yes

Desire to protect assets from divorce or lawsuits

Privacy concerns (public probate avoidance)

Yes

Privacy concerns (public probate avoidance)

Multigenerational planning goals (grandchildren, dynasty trusts)

Yes

Multigenerational planning goals (grandchildren, dynasty trusts)

Professional Advisors

Professional Advisors

Name

Service Provider

Firm

Phone

Professional Advisor Notes

Investment Preferences

What is your objective for this account

Preserving initial investment potential

Generating income and achieving slight growth

Achieving moderate to substantial growth

Seeking maximum growth potential

When do you expect to tap into your account

In less than 5 years

In 6–10 years

In 11–15 years

In 16–20 years

Over the next 10 years, do you expect your income to:

Decline (due to raising children, retirement, slow economy)

Keep pace with inflation

Outpace inflation and grow steadily

Increase considerably

If the value of your account dropped suddenly by 30 percent, would you:

Sell all of your investments and move to cash

Transfer some of your money to more conservative investments

Do nothing and wait for the value to come back

Add to your investments to take advantage of low prices

You can live off your current cash savings and investments for:

0–3 months

4–6 months

7–12 months

More than 1 year

How much risk are you willing to take to achieve a potentially higher return

None. You are risk-averse

A little risk. You are concerned about significant market fluctuations

Moderate risk. You understand the relationship between risk and reward

A lot of risk. You are not concerned with market fluctuations

How knowledgeable do you consider yourself to be about economic issues, personal finance, and investing

Virtually no understanding of the economy, personal finance, and investing

Not very knowledgeable

Somewhat knowledgeable

Very knowledgeable

Investment Objective Profile Score

I am willing to accept limited risk to my investment principal in this account, even if that means this account does not generate significant returns and may not keep pace with inflation. This objective generally focuses on the generation of current income. Accounts with this objective may be invested primarily in fixed income/ bonds, with up to 25% in equities/stocks, but actual investment allocations will differ based on individual client goals, concerns, and market conditions. This objective has historically been the most conservative on a relative basis and has exhibited lower volatility than objectives that allocate a greater portion of investments to the equity/stock markets; however, past performance is no guarantee of future results.

I am willing to accept relatively low risk to my investment principal and will tolerate some volatility to seek a modest level of income and/or objective returns. This objective generally focuses on asset appreciation sufficient to offset inflation over time while also generating current income. This objective may consist of a majority of fixed income/bonds, with up to 45% in equities/stocks, but actual investment allocations will differ based on individual client goals, concerns, and market conditions. This objective has historically exhibited modest volatility compared with objectives that allocate a greater portion of investments to the equity/stock markets over time; however, past performance is no guarantee of future results.

I am willing to accept moderate risk and volatility to my investment principal to seek higher returns. This objective generally targets a balanced asset allocation approach that seeks to provide growth potential and generation of interest or dividend income. This objective may consist of up to 65% in equities/stocks, with the remainder in fixed income/bonds, but actual investment allocations will differ based on individual client goals, concerns, and market conditions. This objective has historically exhibited less overall volatility than objectives that allocate a greater portion of investments to the equity/stock markets over time; however, past performance is no guarantee of future results.

I am willing to accept a relatively higher risk to my investment principal, including greater volatility, to seek higher returns over time. This objective generally targets growth of the portfolio, which may or may not focus on the generation of interest or dividend income. This objective may consist of up to 85% in equities/stocks, with the remainder in fixed income/bonds, but actual investment allocations will differ based on individual client goals, concerns, and market conditions. This objective has exhibited greater market value fluctuations than objectives that allocate a greater portion of investments to the fixed income markets; however, past performance is no guarantee of future results.

I am willing to accept significant risk to my initial principal in order to aggressively seek maximum returns. This objective generally seeks maximum growth potential or generation of income from equities or alternative investments. This long-term-oriented objective is typically invested almost entirely in equities/stocks, with the remainder, if any, in fixed income/bonds or alternative investments, but actual investment allocations will differ based on individual client goals, concerns, and market conditions. This objective has historically offered the highest level of risk and widest market value fluctuations compared to other objectives, especially in the short term; however, past performance is no guarantee of future results.

Documentation

DOWNLOAD THE DOCUMENTS CHECKLIST HERE

Personal Documents

Drop files here or

Accepted file types: pdf, csv, xls, doc, docx, xlsx, jpg, png, Max. file size: 50 MB.

Personal Documents

Bank Information

Linking Your Bank Account

To streamline future transactions — such as funding accounts or paying invoices — you may securely provide your bank account information below. This information will be stored in encrypted form and used only with your authorization. If you prefer, you may leave this section blank and provide details at a later time.

Bank/Financial Institution

Ownership

Names on Account

First Name

Last name

Type

Checking

Savings

Routing/Transit Number

Account Number

Address

City State ZIP Code

Optional:

-Trusted Contact (not a beneficiary but just a person that you authorize your brokerage firm to contact in limited circumstances, such as if your broker has trouble reaching you or has a reasonable belief that your account may be exposed to possible financial exploitation. A trusted contact person must be age 18 or older)

Trusted Contact

First Last

Phone

Relationship

INTAKE FORM

CLIENT LOGIN

Intake Form

Personal Information

Beneficiaries

Beneficiary 1

Beneficiary 2

Contingent Beneficiary 1

Contingent Beneficiary 2

Career Information

Financials

Health & Lifestyle

PROTECTION

Protection

Investment Preferences

Investment Objective Profile Score

Documentation

Bank Information