Putney Oxford- Insurance Questionnaire

General Information

Name:
Date of Birth:
Tobacco User:		Yes No
Spouse/Partner Name:
Date of Birth:
Tobacco User:		Yes No
Children's Name #1:		Age:
Children's Name #2:		Age:
Children's Name #3:		Age:
Children's Name #4:		Age:
Residence Address:
City:
State:
Zip:
Phone:
Residence:		Own Home Rent Live with Parents
Occupation:
I am:		Employee Owner Other
Business Phone:
Fax:
Email:

My Feelings, Concerns and Goals

1. Providing education funds for the children is of.............................................	High Concern Moderate Concern No Concern NA
2. Retirement planning is of.........................	High Concern Moderate Concern No Concern NA
3. Saving a fixed % of income is of...............	High Concern Moderate Concern No Concern NA
4. Insurance on my spouse/partner (and children) is of............................................	High Concern Moderate Concern No Concern NA
5. Assuring an income when I'm sick or hurt and cannot go to work is of..............	High Concern Moderate Concern No Concern NA
6. In the event of my death, Paying off my mortgage and other debts is of..........	High Concern Moderate Concern No Concern NA
7. In the event of my death, Allowing my family to "remain in their own world" is of..............................................................	High Concern Moderate Concern No Concern NA
8. Getting help with my overall insurance planning is of............................................	High Concern Moderate Concern No Concern NA

Overall Planning

1. I participate in a pension/profit sharing plan at work..................................	Yes No Don't Know
2. I have appointed a guardian for my children...............................................	Yes No Don't Know
3. The executor of my estate is familiar with my estate plan...........................	Yes No Don't Know
4. I do a good job managing my income/expense flow...................................	Yes No Don't Know
5. I am in good health and have had no difficulty purchasing insurance.........	Yes No Don't Know
6. My spouse/partner participates in planning our financial affairs..................	Yes No Don't Know

Financial Information

Annual Income - You:	Under $30,000 $30,000 - $60,000 $60,000 - $125,000 Over $125,000	Annual Income - Spouse/Partner:	Under $30,000 $30,000 - $60,000 $60,000 - $125,000 Over $125,000

Total Life Insurance - You:	Under $75,000 $75,000 - $200,000 $200,000 - $500,000 $500,000 - $1,000,000 Over $1,000,000	Total Life Insurance - Spouse/Partner:	Under $75,000 $75,000 - $200,000 $200,000 - $500,000 $500,000 - $1,000,000 Over $1,000,000

Total Assets (Excluding Residence):	Under $60,000 $60,000 - $200,000 $200,000 - $600,000 $600,000 - $1,000,000 Over $1,000,000	Total Liabilities (Excluding Mortgage):	Under $40,000 $40,000 - $150,000 $150,000 - $300,000 $300,000 - $600,000 Over $600,000
Residence Market Value:	$	Residence Outstanding Mortgage:	$

Present Finances:	Life Insurance Cash Values Savings and CDs Money Market Mutual Funds Real Estate Stocks and Bonds US Government Bonds IRA 401(k)/Salary Saving Pension/Profit Sharing Plan	Risk Profile:	I prefer to take almost no financial risk. I am willing to take average risks in order to improve potential rate of return. I am willing to take substantial risks in order to increase potential rate of return.
	Other:

Future Planning

In the near future I expect to: (Check all that apply)
Business:	Borrow money Purchase property Hire key people Pay off a loan Take in a new partner Change employee benefits Purchase insurance Sell business interest	Personal:	Have a child Adopt a child Improve home Buy a home Care for parent Change marital status Inherit assets Retire

I am Interested in Discussing

(Check all that apply)
	Tax favored financial products Ways to reduce estate taxes and expenses Ways for the company to pay my death taxes Ways to provide income for retirement Ways to provide for my family in the event of my death Ways for the company to pay for personal insurance A review of existing insurance Ways to retain key people Ways to reduce employee benefit costs Insurance on children/grandchildren
	Other (Specify):

Additional Information

The following information is important to my/our planning

What Concerns you Most About Your Business?

if business owner, check those areas of concern:
	Business Continuation If you had retired, died or become disabled yesterday, who would own, and who would run your business today?
	Key People - Maximizing Benefits If a key person left you today, would it be because a competitor offered a more attractive benefit package? If a key person died or became disabled today, would it adversely affect your profits?
	Optimizing Personal Benefits Are you getting as much as possible from your business on a tax-favored business?


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