Basic Financial Questions

Are You Employed or Retired?

Gross Annual Income

Do You Have Other Income Sources

Do You Save 10% or More?

Yes

No

Assets

Select the assets you have (select all that apply)

Primary Residence Value

Balance Owed on Primary Residence

Do You Own Investment Property

Liabilities

Have you ever filed for Bankruptcy?

Desired use for your new policy

If you selected multiple which desired use is your main priority?

Share with us a little bit more about what you would like to accomplish with your policy.

Goals

Timeline to start your policy?

How much premium would you like to pay?

Would you like to pay monthly or annually?

Monthly

Annually

TBD

Who is the beneficiary?

Do you have life insurance?

Have you ever used nicotine?

Do you have primary physician?

Do you have travel outside of the U.S. or Canada scheduled in the next two years?

(Skip this part if you are using a phone.)

If you would like us to review any illustrations, please upload it here.

Please upload your Driver's License or State ID here and any medical documentation.

How did you hear about us?

Have you read R. Nelson Nash's "Becoming Your Own Banker?"

Do you own one or more IBC® policies?

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