How will you be using this form?(Required) Insurance Choices(Required) Investment Account Type(Required) Add In(Required) If client will be transferring existing investment accounts, have you asked for account statement(s)?(Required)
Section I - General Information (Applicant 1) Legal Name(Required)
First
Middle
Last
DOB(Required) Check if Not a US Citizen Gender(Required) Visa Type(Required) Green Card Expiration Date(Required) Driver's Licence(Required) Issue Date Expiration Date Current Home Address(Required)
Previous Address(Required)
Is your mailing address different than your home address?(Required) Mailing Address (if different than home address)(Required)
Smoker Status(Required) Smoked in the last 12 Months? Any hazardous sports/activities in the last 3 years?(Required)
Any foreign travel last year or the next two years? Specify location and dates.(Required)
Any tickets/accidents in the last 5 years?(Required)
Section II - Employment Information Current Employer Address(Required)
Company Address(Required)
Type of Organization(Required) c. Date of last format variation(Required) 1. Name(Required)
First
Last
2. Name(Required)
First
Last
3. Name(Required)
First
Last
4. Name(Required)
First
Last
Does the business carry life insurance on the lives of any business officer(s) or partner(s)? Purpose of Insurance (Select all that apply) Is there a written agreement? Provide the date the agreement originated Date of Loan Additional Details: Indicate section letter and question number.
Financial Information Working at Residence Working at Client Site Clients seen in Residence? Contact with outside customers? Choose 1 - Employment Status Insured’s employer or business is a Does the Insured have ownership interest in the business? Does the insured supervise any employees? Premium Paid By Does the Insured intend to change occupation, employer, or employment status?
Section III - Medical Information Past 2 years treated for Cancer, Heart Attack, Heart Disease, Chest Pain, Stroke, Alcohol/Drug Use, or Immune Disorder (not include HIV tests)? Past 90 days admitted or advised to medical facility, or had surgery (except pregnancy)? Next 90 days, any medical tests or examinations scheduled (except pregnancy related)? Do you currently need assistance with any of the following everyday activities? During the past 10 years, have you been medically diagnosed or treated for any of the following Are you currently receiving Social Security Disability or Medi-Cal? Do you currently use or have you used in the past 12 months In past 12 months have you been advised to have any special testing or surgery that has not yet been performed? Aware of any symptoms or complaints for which you plan to seek medical advice or treatment? In past 12 months have you been hospitalized, received rehabilitative services including physical therapy, occupational therapy, home care or been confined to a nursing home or residential care facility? In past 12 months have you received disability income or workers' compensation or any other state disability? In past 5 years, have you had or been issued a handicap tag? In past 5 years, have you been declined for long term care insurance? Substance Abuse Endocrine (Glandular) Disorders Gastrointestinal Disorders Cancer Circulatory Disorders Genitourinary Disorders Musculoskeletal (bone or joint) Disorders Blood Disorders Eye Disorders Neurological Disorders Respiratory Disorders Family (Mother, Father Siblings) In the past 5 years, have you consulted a Health Care Professional? Primary Doctor Address
Primary Doctor Last Visit Date List All Medications in the last 2 years (One per line) List the medication name, the prescribing physician name and the dosage/frequency of use.
General Information Applicant 2 Legal Name
First
Last
DOB US Citizen Issue Date Expiration Date Current Home Address
Former Address
Smoker (Past 12mo)
Medical Information Applicant 2 Do you currently need assistance with any of the following everyday activities? During the past 10 years, have you been medically diagnosed or treated for any of the following Are you currently receiving Social Security Disability or Medi-Cal? Do you currently use or have you used in the past 12 months In past 12 months have you been advised to have any special testing or surgery that has not yet been performed? Aware of any symptoms or complaints for which you plan to seek medical advice or treatment? In past 12 months have you been hospitalized, received rehabilitative services including physical therapy, occupational therapy, home care or been confined to a nursing home or residential care facility? In past 12 months have you received disability income or workers' compensation or any other state disability? In past 5 years, have you had or been issued a handicap tag? In past 5 years, have you been declined for long term care insurance? Substance Abuse Endocrine (Glandular) Disorders Gastrointestinal Disorders Cancer Circulatory Disorders Genitourinary Disorders Musculoskeletal (bone or joint) Disorders Blood Disorders Eye Disorders Neurological Disorders Respiratory Disorders Family (Mother, Father Siblings) In the past 5 years, have you consulted a Health Care Professional? Primary Physician Address
Last Visit List All Medications in the last 2 years (One per line) List the medication name, the prescribing physician name and the dosage/frequency of use.
Section IV - INFORCE LONG TERM CARE (Applicant 1) 1. Have a policy, certificate or application with this or any other company providing long term care insurance? 2. Have another long-term care insurance policy or certificate in force during the past 12 months? Lapse Date Q1 Date Q1 Do you intend to replace this policy? Q2 Date Q2 Do you intend to replace this policy? Q3 Date Q3 Do you intend to replace this policy?
Section IV - INFORCE LONG TERM CARE (Applicant 2) 4. Have a policy, certificate or application with this or any other company providing long term care insurance? 5. Have another long-term care insurance policy or certificate in force during the past 12 months? Lapse Date 6. Intend to replace any of your long-term care, medical or health insurance coverage with this policy? Q4 Date Q4 Do you intend to replace this policy? Q5 Date Q5 Do you intend to replace this policy? Q6 Date Q6 Do you intend to replace this policy?
Section IV - INFORCE DISABILITY INSURANCE Does the Applicant have any Group Coverage and/or other DI in force, pending, or contemplated with other Companies? Are we replacing existing coverage? Have you ever had Life, Disability, or Health insurance declined, canceled, or not renewed? Date of Decline or Rating
Section IV - INFORCE LIFE INSURANCE Does the applicant have INFORCE LIFE INSURANCE? How many INFORCE LIFE INSURANCE POLICIES? Inforce Policy 1: Do you intend to replace this policy? Inforce Policy 2: Do you intend to replace this policy? Inforce Policy 3: Do you intend to replace this policy? Inforce Policy 4: Do you intend to replace this policy? Inforce Policy 5: Do you intend to replace this policy? Is this a replacement of coverage from another company? Have you ever been declined or rated by another company? Decline Date
Section V - OWNER: Who owns the policy? Group Coverage? Group Coverage? Group Coverage? Group Coverage?
Section VI - JUVENILE INFORMATION Juvenile Legal Name(Required)
First
Middle
Last
Juvenile DOB US Citizen Juvenile Current Address
Any hazardous sports/activities in the last 3 years?(Required)
Previous Address
Any foreign travel last year or the next two years? Specify location and dates.(Required)
Any tickets/accidents in the last 5 years?(Required) Other Owner Name
First
Last
Other Owner DOB Other Owner Address
INVESTMENTS Employment Status This field is hidden when viewing the form
(DNU) 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? 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? * If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application. This field is hidden when viewing the form
OLD DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company? INV - Are you a director, 10% shareholder or policy-making officer of a publicly held company? Is this a business checking account? Name of authorized signer 1
First
Last
Name of authorized signer 2
First
Last
Trusted Contact Name
First
Last
Investment - Joint Account
Investment - Corporate Account How many joint applicants or members?
Joint Applicant/Member 1 Name
First
Last
DOB Address
Is your mailing address Different? Mailing Address (if different)
Employment Status This field is hidden when viewing the form
DNU 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? JA1 -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? * If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application. This field is hidden when viewing the form
DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company? JA1 -Are you a director, 10% shareholder or policy-making officer of a publicly held company? Role Title or Capacity
Joint Applicant/Member 2 Name
First
Last
DOB Address
Is your mailing address Different? Mailing Address (if different)
Employment Status This field is hidden when viewing the form
DNU 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? JA2 - 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? * If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application. This field is hidden when viewing the form
DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company? JA2 -Are you a director, 10% shareholder or policy-making officer of a publicly held company? Role Title or Capacity
Joint Applicant/Member 3 Name
First
Last
DOB Address
Is your mailing address Different? Mailing Address (if different)
Employment Status This field is hidden when viewing the form
DNU 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? JA3 - 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? * If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application. This field is hidden when viewing the form
DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company? JA3 -Are you a director, 10% shareholder or policy-making officer of a publicly held company? Role Title or Capacity
Joint Applicant/Member 4 Name
First
Last
DOB Address
Is your mailing address Different? Mailing Address (if different)
Employment Status This field is hidden when viewing the form
DNU 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? JA4 -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? * If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application. This field is hidden when viewing the form
DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company? JA4 -Are you a director, 10% shareholder or policy-making officer of a publicly held company? Role Title or Capacity
Joint Applicant/Member 5 Name
First
Last
DOB Address
Is your mailing address Different? Mailing Address (if different)
Employment Status This field is hidden when viewing the form
DNU 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? JA5 - 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? * If "Yes," you must attach a letter from your or your immediate family member's employer or affiliated broker-dealer approving the establishment of your account when submitting this application. This field is hidden when viewing the form
DNU Are you a director, 10% shareholder or policy-making officer of a publicly held company? JA5 - Are you a director, 10% shareholder or policy-making officer of a publicly held company? Role Title or Capacity Type of joint tenancy
UTMA/UGMA Account Minor Owner - Name
First
Last
Minor Owner - DOB
Traditional IRA, Rollover IRA, Roth IRA Account IRA Account Type Add Beneficiaries or Trust Is client currently taking RMDs
RMD Info How would client like Required Minimum Distributions (RMD) sent Does client want Federal Tax withheld from RMD distribution Does client want State Tax withheld from RMD distribution
Inherited IRA Account Add Beneficiaries or Trust Date of birth of original IRA depositor (decedent) Date of death of original IRA depositor (decedent)
Simple or SEP-IRA Account Is SEP a passthrough entity i.e. under SSN of account owner
529 Account
Individual Transfer on Death Account
Joint Tenant Transfer on Death Account Add Beneficiaries or Trust
Corporate Account Type of Organization List all members who are greater than or equal to 10% owner of the corporation (One per line, %)
Corporation Address
Is the mailing address of the corporation different than listed above? Corporation Mailing Address (if different)
Date of Incorporation
Advisor Alert Alert Received We will need a Copy of the Articles of Incorporation
Company Retirement Account: Solo 401(k), Profit Sharing, DB Pension Plan Account Type of Plan Account Being Opened Company Business Structure Plan Effective Date
Advisor Alert Alert Received We will need a Copy of the 401(k) Plan Document
Trust/Trustees How many Trustees? How many Trusts?
Trustee 1 Trustee 1 Date Established
Trustee 2 Trustee 2 Date Established
Trustee 3 Trust 3 Date Established
Trust 1 Trust Date Established
Trust 2 Trust Date Established
Trust 3 Trust Date Established
Beneficiaries
BENEFICIARIES How Many Beneficiaries?(Required)
Beneficiary 1 Beneficiary 1 Date of Birth(Required)
Beneficiary 2 Beneficiary 2 Date of Birth(Required)
Contingent Beneficiary 1 Contingent Beneficiary 1 Date of Birth(Required)
Contingent Beneficiary 2 Contingent Beneficiary 2 Date of Birth(Required)
Trust Account Trust type Check appropriate box if the Irrevocable trust is a: Decedent’s name
First
Last
Advisor Alert Alert Received We will need a Copy of the Certification of Trust (or first pages showing Trust title, and last page(s) with trustee and notary dated signatures)
