Lic. #0C80949    
BUSINESS CHECK-UP FORM  
First Name Last Name
Phone -- Email
Company Name
Type of Industry
Are you Married? YES NO Do you have Children? YES NO
Do you have a Business Partner(s)? YES NO
List the name(s) of any and all Business Partner(s) and their Company Positions?
Partner Name Company Position
Partner Name Company Position
What type of Business Entity are you?
C Corp. S Corp. Sole Proprietor LLC Limited Partnership Other
Do you have Employees? YES NO Do you offer Employee Benefits? YES NO
If YES, what type of benefits are currently offered to your employees?
Health Insurance Retirement/401k Profit Sharing Incentives Other
Is offering benefits to your employees important to you? YES NO
Is a Retirement Plan something that is important to you? YES NO
Do you have a Company Retirment Plan(s) or Company Savings Plan(s)? YES NO
If YES, what type of Retirement Plan(s) or Savings Plan(s) do you currently have in place?
Life Insurance Retirement/401k Annuities Savings Account Other
Do you have a written Monthly Business Budget that you currently adhere to? YES NO
Do you have a Business Emergency Account? YES NO
SPECIAL NOTE: A solid Financial Cushion is considered to be 3 to 6 months of Operating Expennses.
Do you have a Comprehensive Life Insurance Plan(s)? YES NO
If YES, what type of Comprehensive Life Insurance Plan(s) do you currently have in place?
Key Person Buy/Sell Business Owner Other
Is a Comprehensive Life Insurance Plan something that is important to you? YES NO
Do you have any Comprehensive Disability/Critical Care Plan(s) to cover injury or illness? YES NO
If YES, what type of Comprehensive Disability/Critical care Plan(s) do you currently have in place?
Key Person Buy/Sell Business Owner Other
Is a Comprehensive Disability/Critical Care Plan something that is important to you? YES NO
What is the status of the Commercial Building you currently occupy? OWN LEASE RENT
Do you have any Business Debt you would like to eliminate right now? YES NO
Do you have a Company Trust? YES NO
Is having a Company Trust something that is imprtant to you? YES NO
Would you like to pay less Taxes? YES NO
Do you have Commercial Auto Insurance? YES NO
Do you have Business Insurance? YES NO
If YES, what type of Insurance Plan(s) do you currently have in place?
General Liability Professional Liabilty Business Owner Policy Property Equiptment
Garage Liability Work Comp Landlord Liabilty Other
Do you have a Commercial Umbrella Policy? YES NO

 

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