Lic. #0C80949    
PERSONAL CHECK-UP FORM  
First Name Last Name
Phone -- Email
What is your current Employment Status?
Employed Unemployed Self-Employed Retired Disability Other
Are you Married? YES NO If YES, how long?
First Name Last Name
What is your current Employment Status of your spouse?
Employed Unemployed Self-Employed Retired Disability Other
Do you have Children? YES NO If YES, how many?
Name Age Name Age
Name Age Name Age
If you have children, is a college education important to you and your family? YES NO Do you have a personal plan for your children's financial future? YES NO
If YES, what type of plan(s) do you currently have in place to secure the financial future of your children?
Life Insurance 529 Annuities Savings Account Other
Do you have a written Monthly Budget that you and your family currently adhere to? YES NO
Do you have a Savings Account or Emergency Money? YES NO
SPECIAL NOTE: A solid Finacial Cushion is considered to be 3 to 6 months of Operating Expenses.
Is a Retirement Plan something that is important to you and your family? YES NO
Have you started a Savings Account(s) or implemented a Retirement Plan(s)? YES NO
If YES, what type of Savings Account(s) or Retirement Plan(s) do you currently have in place?
Life Insurance IRA/401 Annuities Savings Account Other
Do you have any Comprehensive Life Insurance Plan(s)? YES NO
If YES, what type of Comprehensive Life Insurance Plan(s) do you currently have in place?
Term Life Permanent Life 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?
Critical Care Long-Term Care Disability Insurance Other
Is a Comprehensive Disability/Critical Care Plan something that is important to you? YES NO
What is the status of the Home you currently occupy? OWN LEASE RENT
If you are an OWNER, what are your current mortgage rate(s)? (Please list First, Second, Third, Equity Line, etc...)
Mortgage Type Interest Rate Mortgage Type Interest Rate
Do you have any Personal Debt you would like to eliminate right now? YES NO
Do you have a Personal or Family Trust? YES NO
Is having a Personal or Family Trust something that is important to you? YES NO
Would you like to pay less Taxes? YES NO
Do you currently have Auto Insurance? YES NO
Do you currently have Homeowner's Insurance? YES NO
Do you have Recreational Vehicles with Insurance? (Motorcycle, RV, Trailer, Boat, Watercraft, etc.) YES NO
Do you have a Personal Umbrella Policy? YES NO

 

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