Delta Financial - Future Expenses

First...

Date of Birth:

Gender:

Height:

Weight:

Have you used any tobacco products within the past three years?

Yes

No

Do you have any heart related problems or are you taking medications for them?

Yes

No

Have you ever had cancer of any kind?

Yes

No

Have any member of your immediate family died prior to age 50 because of cancer or cardiac problems?

Yes

No

Are you planning foreign travel?

Yes

No

If Yes, when, and where to?

When?

Where?

Second, some questions about your future expense...
(Please click applicable expenses)

College Expenses

Please tell us about your children

Age	Expected Years Enrolled	Estimated annual education costs, including room and board

Pay Off Mortgage

Original Mortgage Amount:

Amorization Period: number of years

Second Mortgage Yes No

If yes, Date financed:

Current Payoff balance:

Estate Transfer Expenses

Approximate total value of your estate, including liquid assets, real estate, company ownership, and all other non-liquid assets.

Last step… How do you want us to communicate?

I authorize release of the personal information on this form to my financial consultant or financial advisor.

Financial Consultant or Financial Advisor Name

Phone

Firm

-OR-

I authorize release of the personal information on this form solely for the purpose of receiving coverage recommendations from a licensed advisor that you refer to me.

(This service is free and without obligation. You will not be asked to sign anything at the time of your initial meeting. You should expect a call within one week.)

-OR-

I do not authorize release of this information. Please call me.

Your Name:

City:

State:

Phone:

Best time to call: