Retirement Planning · Offline Version

Client Intake

About 7–12 minutes. Estimates are completely fine. If you do not know an answer, choose Not sure or leave it blank. Your advisor will review everything with you.

What happens next:
1. Answer the questions.
2. Click Complete My Form at the end.
3. Your answers will be securely submitted to your advisor.
4. Your advisor will review the information with you before discussing recommendations.

You do not need to calculate anything perfectly.

Please do not enter: Social Security number, bank/routing/account number, driver's-license/passport number, passwords, or medical records. Date of birth may be requested because age and exact birth date can affect retirement and insurance illustration inputs.

1. About You

Basic information so your advisor knows who the plan is for.

Your name

Best email address

Best phone number

Your date of birthUsed for retirement timing and carrier illustration preparation. Do not enter an SSN or government-ID number.

Sex used for insurance illustrationSome carrier illustration systems require this input for preliminary pricing. This is not a medical question.

Your age

Spouse / partner name

Spouse / partner date of birth

Spouse / partner sex used for insurance illustration

Spouse / partner age

State

Marital status

Your work status

Spouse / partner work status

When would you like to retire?

Number of people financially dependent on you

Occupation / work role

This information helps your advisor understand your financial situation and prepare an accurate planning discussion. If you are unsure, use an estimate or leave the item blank when allowed.

2. Your Monthly Picture

Round numbers are fine. This helps us see what is comfortable and sustainable.

What is your approximate annual household gross income?

What is your approximate monthly household net income?

Do you rent or own your home?

How much are your total monthly auto payments?

Add together all car, truck, motorcycle, or other vehicle loan/lease payments.

What are your remaining monthly household expenses?

Do not include the mortgage/rent or auto payments you entered above. Include food, utilities, insurance, fuel, phones, subscriptions, childcare, entertainment, and other normal monthly spending.

Simple rule: Housing first → Auto payments second → Everything else third. Do not enter the same expense twice.

What is your approximate readily accessible liquid savings?

Checking, savings, HYSA, money market, or similar.

What monthly amount could you comfortably commit toward long-term financial goals?

Do you have a one-time amount you may want to reposition or invest?

Where would those one-time funds come from?

Retirement Accounts & Other Assets

Only add the accounts that matter. You do not need exact balances.

Debts

Optional detail for planning: add outstanding balances such as mortgage, auto loans, credit cards, student loans, or other debts. Your monthly housing and auto payments were already asked above, so you do not need to calculate them again.

This information helps your advisor understand your financial situation and prepare an accurate planning discussion. If you are unsure, use an estimate or leave the item blank when allowed.

3. Retirement Income

Think about the monthly lifestyle you would like to maintain.

Desired monthly retirement income

Estimated monthly Social Security — you

Estimated monthly Social Security — spouse

Planned Social Security start age

Other guaranteed monthly income before Social Security

What is it?

Other guaranteed monthly income after Social Security

What is it?

This information helps your advisor understand your financial situation and prepare an accurate planning discussion. If you are unsure, use an estimate or leave the item blank when allowed.

5. What Matters Most to You?

There are no right or wrong answers.

Primary financial goal

Biggest financial concern

Main retirement-income objective

Could you need to move long-term funds early?

About what % of proposed long-term funds might you need within one year?

If a lump sum is used, how would you prefer it to be allocated?

Financial-product experience

Approximate tax bracket %

Approximate liquid net worth

Cash and investments you could reasonably access without selling a home or business.

Any major financial change expected?

What is your priority for predictable or guaranteed retirement income?

What is your liquidity priority?

Preliminary risk profile: Complete the questions above and this box will provide a discussion-oriented risk profile based on your time horizon, liquidity, goals, concerns, and experience.

What is your risk tolerance? This is a preliminary planning aid, not an investment recommendation or carrier suitability determination. You may choose a different answer.

Existing annuity information, if applicable

Approximate value of existing annuities

Years of surrender charges remaining, if known

Have you exchanged/replaced an annuity before?

When would you want retirement income to begin?

If income is needed, should it cover one person or both spouses?

Anything else you want your advisor to know?

This information helps your advisor understand your financial situation and prepare an accurate planning discussion. If you are unsure, use an estimate or leave the item blank when allowed.

Optional Plan Tailoring

These detailed questions are optional. Open only the sections you want to answer yourself. If you prefer, leave them closed and your advisor can assist you through them.

Family Protection Basics

Would you like to provide basic information about your current life-insurance protection and related planning considerations?

Yes — answer these questions No — have my advisor assist me

This section is currently closed.

Current total life-insurance coverage

If you know it, estimated additional coverage needed

Do you want some life insurance to last your entire life?

Highest credit-card/personal-loan APR %

Tobacco / nicotine useFor preliminary life-insurance illustration assumptions only. No medical details are requested.

Would this potentially replace existing life insurance?

Insurance Illustration Details

Would you like to answer the more specific ownership, funding, distribution, exchange, and illustration-design questions now?

Yes — answer these questions No — have my advisor assist me

This section is currently closed.

Illustration Preparation Details

Complete what you know. These questions reduce follow-up when your advisor prepares a carrier illustration. Carrier design choices and current rates will still be reviewed by your advisor.

Will the insured also be the policy owner?

If someone else will own the policy, who?

Owner date of birth, if different

Owner sex used for insurance illustration, if different

How would you most likely fund a new life-insurance policy?

Approximate first-year lump sum for life insurance, if any

What should a life-insurance illustration focus on?

Should the illustration be designed to avoid Modified Endowment Contract (MEC) status when practical?Your advisor will determine the appropriate carrier setting. This question only records your planning preference.

Do you expect to use policy loans or withdrawals later?

If yes, about what age might distributions begin?

Approximate desired monthly policy distribution, if applicable

Could existing life insurance or an annuity be exchanged into a new contract?

Approximate amount that could be exchanged, if known

What type of contract might be exchanged?

Has a carrier or advisor previously given you an insurance rate class?This does not replace underwriting. Final classification is determined by the carrier.

Rider & Benefit Preferences

Would you like to identify which optional insurance benefits or rider features may be worth discussing with your advisor?

Yes — answer these questions No — have my advisor assist me

This section is currently closed.

Life Insurance Rider & Benefit Preferences

These questions help your advisor prepare a carrier illustration draft. They do not guarantee rider availability, underwriting approval, or final recommendation. Current carrier/state rules must be verified.

Would access to a portion of the death benefit for qualifying terminal illness be important to you?

Would access to a portion of the death benefit for qualifying chronic illness be important to you?

Would access to a portion of the death benefit for qualifying critical illness be important to you?

Would access to a portion of the death benefit for qualifying critical injury be important to you?

Would a benefit related to qualifying Alzheimer's disease or severe cognitive impairment be important to you?

Would you like your advisor to evaluate a potential lifetime-income feature from permanent life insurance later in retirement?

Do you expect policy loans or withdrawals to be an important part of your long-term strategy?

Would you prefer a feature designed to reduce lapse risk when specific funding requirements are met?

If making a larger premium payment, would you want your advisor to evaluate systematic monthly allocation into indexed segments?

Is charitable giving part of your legacy plan?

Should your advisor evaluate coverage or an additional rider involving another insured person?

If available, would you like voluntary value-added wellness, financial, or life-planning services reviewed?

Family Protection Estimate

Would you like to provide the amounts your advisor can use to estimate survivor, debt-payoff, education, final-expense, and legacy needs?

Yes — answer these questions No — have my advisor assist me

This section is currently closed.

Simple family protection estimate

Debts you would want paid off for survivors

Annual income survivors may need replaced

How many years might that income be needed?

Education / family funding goal

Final expenses

Legacy / inheritance goal

Liquid assets available to survivors

Main protection need

This information helps your advisor understand your financial situation and prepare an accurate planning discussion. If you are unsure, use an estimate or leave the item blank when allowed.

6. Review & Complete

You are almost done.

Do not worry about blanks or estimates. Your advisor will review your answers with you before discussing options.

Offline version: nothing is sent over the internet. After completing the form, use Print / Save as PDF to create a copy for your advisor.

I confirm that I did not enter an SSN, full bank/routing/account number, driver's-license/passport number, password, or medical record.

This information helps your advisor understand your financial situation and prepare an accurate planning discussion. If you are unsure, use an estimate or leave the item blank when allowed.