Client Questionnaire – Big Financial Services

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QUESTIONNAIRE

Client Questionnaire

Name (Client 1)

Date

First Name

Last Name

Marital Status

Age

Primary Address

Primary Address

Street Address

Address Line 2

City

State

ZIP Code

Phone

Mobile

Occupation

Work Name

Work Address

Work Address

Street Address

Address Line 2

State

ZIP Code

First Name (Client 2)

Last Name (Client 2)

Wedding Anniversary

Age

Phone

Mobile

Occupation

Work Name

Work Address

Street Address

Address Line 2

State

ZIP Code

Name

Relationship

Residence

Marital Status

Parental Status

Notes (Pertaining to Family Dynamics)

Whose

Source/Type

Net Monthly Amount

Survivor Benefit % or $

Notes

Total Monthly Income

Total Annual Income

Banks

Name of Bank

Account Type

Account Balance

Qual./Nonqual.

% Rate

Renewal/Maturity Date

Owner/Title

ToD

Total Bank Balance

Brokerage Accounts

Name of Brokerage Firm

Account Type

Account Balance

Qual./Nonqual.

Owner/Title

ToD or PoD

Total Brokerage Balance

Securities - Non-Brokerage

Name/Symbol of Security

Security Type

Number of Shares/Units

Current Values

% Rate

Renewal/Maturity Rate

Owner/Title

ToD to PoD

Total Securities (Non-Brokerage) Shares/Units

Total Securities (Non-Brokerage) Value

Annuities

Name of Insurance Company

Annuity Type

Account Value

Qual./Nonqual.

% Rate

Surrender Period Status

Owner

Beneficiary

Total Annuities Value

Total Financial Assets

Real Estate

Address/Location

Type

Current Value

Owner

Mortgage Balance

Total Real Estate Value

Total Assets (Including Real Estate)

Liabilities

Liability Company/Source

Type

Balance Due

Payment Amount

Payment Frequency

Owner

Total Liability Balance

Total Liability Payment

Total Net Worth (Including Real Estate)

Total Net Worth (Not Including Primary Residence)

Life Insurance

Insured

Company

Insurance Amount

Premium Status

Policy Type

Cash Value

Loan Value

Owner

Beneficiary

Total Life Insurance Amount (Client 1)

Total Life Insurance Amount (Client 2)

Long Term Care Insurance

Insured

Company

Daily/Monthly Benefit

Premium Status

Benefit Term

Inflation Factor

Owner

Notes (Pertaining to Income, Assets, Liabilities and Risk Management)

Areas of Concern

Goals and Objectives

Notes

Client 1 Initials

Client 2 Initials

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