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Thanks for your questions about coverage for lost earnings.
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?
2. Some Question to recommend coverage for lost earnings
.
At what age do you expect to retire?
What are your current after tax earnings?
How much of those earnings do you spend on yourself?
(clothing, transportation, entertainment, etc.)
Approximately
At what rate do you expect your earnings to increase?
%/year
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 to call within one week.)
I do not authorize release of this information. Please call me.
Your Name:
City:
State:
Phone:
Best time to call:
We pledge to keep private the personal information you choose to share. We do not sell or distribute any information about you, except for that needed by your financial consultant or financial advisor.
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