1. What is your name?

2.Date of Birth:

3.Occupation:

4.Nicotine use?
—Please choose an option—CigarettesCigarChewing Tobabcco/SnuffVapeNo
5.Do you partake in any high-risk activities or hobbies? If yes, please specify:

6. Married?
—Please choose an option—YesNo
7. Children? If yes, please provide ages, names not necessary at this point. (Leave blank if no)

8. What is your current annual income?
—Please choose an option—Less than $50k/Year$50K-$100K$100k-$250k$250k-$500k$500k+
9. Total value of your current savings and investments:
—Please choose an option—Less than $50K$50K-$100k$100k-$250k$250k-$500k$500k-$1M$1M-$3M$3M-$5M$5M+
10. Total value of your tangible assets (real estate, vehicles, etc.):
—Please choose an option—Less Than $100k$100k-$250k$250k-$500k$500k-$1M$1M-$3M$3M-$5M$5M+
11. What are your plans for retirement?

12. Do you wish to leave a legacy or donation to a particular cause? If yes, please specify:
—Please choose an option—YesNoNot Sure

13. Do you currently have any life insurance policies? If yes, please specify the type and coverage amount.
—Please choose an option—YesNo
—Please choose an option—Work PolicyTerm PolicyPermanent (sometimes refered to as whole life)Not Sure
14. What are your current monthly expenses?
—Please choose an option—Less than $500$500-$1,000$1,000-$3,000$3,000-$5,000$5,000-$10,000$10,000+
15. Do you have an emergency fund in place?
—Please choose an option—YesNo
16. Have you done any estate planning? Do you have a will, trust, or other estate planning tools in place? If yes, please specify: