Case Design - Fact Finder Date: _________________ Advisor:____________________________________________________________ Business Phone:__________________________ Mobile Phone: _______________________________ Email: __________________________________ Referred by: _________________________________
□Non-Tobacco □Tobacco □Best Preferred □2nd Best Preferred □3 Best Preferred/Standard Plus □Standard □ Table Rated__________ Female: _____________________________________________ DOB: _____________ □Non-Tobacco □Tobacco □Best Preferred □2nd Best Preferred □3 Best Preferred/Standard Plus □Standard □ Table Rated__________ Male: _______________________________________________ DOB: _____________ rd
rd
Issue State: ________ Relationship:
□Existing Client □Referral from Advisor □Friend □New Relationship
Cash & Equivalents: Marketable Securities: Real Estate: Business: Qualified Plans: Other Assets:
$ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________
Total Net Worth:
=================== $ _________________
Occupation: ______________________________ Net After Tax Income: $ ____________________ Important notes about financials: ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________
Inforce Mr:
Premium $____________ Cash Value $_________ Death Benefit $___________ Carrier__________
Inforce Mrs:
Premium $____________ Cash Value $_________ Death Benefit $___________ Carrier__________
Inforce Joint: Premium $____________ Cash Value $_________ Death Benefit $___________ Carrier__________ Please provide ledgers for any inforce insurance. Please also specify any inforce policies to be considered for replacement.
Additional Insurance Needed: Mr. $ ________________ Mrs. $ ________________ Joint $ ______________ Reason for New Insurance: ___________________________________________________________________ (For example, Estate Planning, Income Supplement, Key Person, Buy Sell, Deferred Compensation)
Last Client Meeting: _______ Have any illustrations been presented to client?
□ No □ Yes (please provide copies)
Case Notes: _________________________________________________________________________________________ _________________________________________________________________________________________ Daniel P. Wachs, CFP, ChFC, CLU
(630) 445-1399 - Office (630) 848-9606 - Facsimile (312) 480-0092 - Mobile 1431 Opus Place, Suite 630, Downers Grove, IL 60515