Saving money on your health insurance & prescription drug premium

Protecting your independence & assets with extended health care planning

Safeguarding your family & their future with life insurance

Increasing & protecting your retirement

Which of these are you interested in getting more information on today?

Suitability Documentation

NEEDS ANALYSIS PROFILE

BASIC INFORMATION

PLEASE CHOOSE WHETHER THE CLIENT IS SINGLE, MARRIED, OR WIDOWED SINGLE MARRIED WIDOWED

CONTACT INFORMATION CLIENT 1 CLIENT 2

First Name Last Name Date of Birth Phone Email Street Address City, State, Zip Employer/Retired from Occupation Any previous marriages? Number of children together Number of children from previous marriage Number of grandchildren Veteran

HEALTH INFORMATION CLIENT 1 CLIENT 2

Date of last doctor visit? Primary care physician Doctors (list specialists & phone #s) Current health issues What do you take medications for?

ARE YOU ON MEDICARE? IF YES, I NEED TO SEE YOUR MEDICARE CARD. MEDICARE INFORMATION

CLIENT 1 CLIENT 2 Medicare Number Part A Date Part B Date Extra Help/Reduced Cost Sharing/Premium Subsidy Medicare Reference ID# and Password

NEEDS ANALYSIS PROFILE

WHO DO YOU CARRY YOUR _____________ INSURANCE WITH? IF THEY HAVE COVERAGE, ASK: HOW IS THAT WORKING FOR YOU? IF NOT, ASK: HOW COME?

INSURANCE INFORMATION CLIENT 1 CLIENT 2

Health ins carrier, plan Health ins premium PDP ins carrier, plan PDP ins premium Life ins carrier Life ins type (term, WL, UL) Life ins premium Dental ins carrier, type Dental ins premium HIP ins carrier HIP ins premium Cancer ins carrier, type Cancer ins premium LTC carrier, benefit amount LTC premium

DO YOU HAVE ANY OF THE FOLLOWING PLANNING DOCUMENTS

CLIENT 1 CLIENT 2 Will Trust Last updated Executor/Successor Trustee Durable POA Advance Medical Directive Healthcare Proxy Any dependents/parents with special needs Who does your taxes? A desire to help a charity

NEEDS ANALYSIS PROFILE

SUITABILITY REQUIREMENTS

MOST PEOPLE GET INSURANCE TO PROTECT THEIR ASSETS. I ASSUME YOU WANT YOUR ASSETS PROTECTED AS WELL, CORRECT?

o YESo NO

IS YOUR HOUSE PAID FOR? o YESo NO

HOW MANY YEARS ARE LEFT ON YOUR MORTAGE? _______ OUTSTANDING MORTGAGE AMOUNT? _______

ARE YOUR CARS PAID FOR? o YESo NO

PLANS TO REPLACE YOUR CAR? o YESo NO

DO YOU HAVE ANY OF THE FOLLOWING…

ARE YOU PAYING TAXES ON YOUR SOCIAL SECURITY INCOME?THANK YOU. THIS IS ALL PART OF OUR SUITABILITY REQUIREMENTS.

INCOME CLIENT 1 CLIENT 2

Employer Social Security Pension IRA Distributions Interest Other

o Checking Accounto Savings Accounto Money Marketo CDs

o Fixed Annuitieso Fixed Indexed Annuitieso Variable Annuitieso Cash Value Life Insurance

o Stockso Bondso Mutual Fundso Real Estate

o 401Ko 403Bo IRAo Roth IRA

o Other

NEEDS ANALYSIS PROFILE

ESTATE ASSET NAME

TYPE/PRODUCT CLIENT 1 AMOUNT

CLIENT 2 AMOUNT Q/NQ

MONTHLY CONTRIBUTIONS

AVERAGE RETURN % NOTES

HOW DO YOU FEEL ABOUT YOUR RETURNS? _________________________________________ ______________________________________________________________________________

WHAT ARE YOUR GREATEST CONCERNS RIGHT NOW REGARDING ANY OF THE THINGS THAT WE HAVE JUST TALKED ABOUT? _______________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

JUST GIVE ME A MINUTE TO LOOK THIS OVER, OKAY? DO YOU KNOW WHAT I SEE HERE?

I WOULD LIKE TO COMPLIMENT YOU ON ____________________________________________

I DO SEE SOMETHING IN YOUR PLAN THAT I WOULD LIKE TO DISCUSS WITH YOU. DO YOU KNOW WHAT IT IS?

WOULD IT BE OKAY IF I SHOWED YOU HOW __________________________________________

SIGNATURE: _______________________________________ DATE: _______________________

SIGNATURE: _______________________________________ DATE: _______________________

NEEDS ANALYSIS PROFILE

LIFE INSURANCE POLICY REVIEW

LIFE INSURANCE POLICY #1 CLIENT 1 CLIENT 2

Carrier/Company Face Amount/Death Benefit Annual Premium Type (Term, UL, Whole Life) Policy Number Effective Date Cash Value Paid Up Insurance Beneficiaries

LIFE INSURANCE POLICY #2 CLIENT 1 CLIENT 2

Carrier/Company Face Amount/Death Benefit Annual Premium Type (Term, UL, Whole Life) Policy Number Effective Date Cash Value Paid Up Insurance Beneficiaries

LIFE INSURANCE POLICY #3 CLIENT 1 CLIENT 2

Carrier/Company Face Amount/Death Benefit Annual Premium Type (Term, UL, Whole Life) Policy Number Effective Date Cash Value Paid Up Insurance Beneficiaries

NEEDS ANALYSIS PROFILE

ANNUITY REVIEW

What kind of annuity do you have? ________________________________________________ _____________________________________________________________________________

What is the policy effective date? _________________________________________________ _____________________________________________________________________________

Name of the carrier & product? ___________________________________________________ _____________________________________________________________________________

Is it out of surrender? YES NO If not, what is the surrender charge? _______________________________________________ _____________________________________________________________________________

What is the surrender value? _____________________________________________________

What is the cash value? _________________________________________________________

What are the riders on the annuity? _______________________________________________ _____________________________________________________________________________

Is there a Market Value Adjustment? YES NO If so, what is it? ________________________________________________________________

Is it qualified or non-qualified? QUALIFIED NON-QUALIFIED

Why did you purchase this annuity? _______________________________________________ _____________________________________________________________________________

Have you taken any distributions/income? YES NO If so, how much? _______________________________________________________________ _____________________________________________________________________________

NEEDS ANALYSIS PROFILE

EXTENDED HEALTH CARE QUESTIONNAIRE

Have you ever looked into a long-term care plan before? YES NO How come you have/have not? ____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Where would you prefer to receive care? YOUR HOME NURSING HOME

Are you familiar with the costs of long-term care? _____________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Have you ever known anyone who has needed care? YES NO Tell me about it… _______________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Which asset would you sell first to pay for your care? __________________________________

How long would your assets last before you would have to sell your home?________________

Your long-term care options are based upon your health and your finances.

Are you more concerned about a certain amount of coverage or a certain budget amount? ____ ______________________________________________________________________________

What would that be? ____________________________________________________________

NEEDS ANALYSIS PROFILE

SAVINGS QUESTIONNAIRE

Client(s): __________________________________________________________

Why did you choose your current investments?

Are you satisfied with the returns on your investments?

Has your investment strategy changed to reflect your current needs?

Are you currently, or do you ever plan to “live-on” the principal or interest from your investments?

Which investment are you least satisfied with?

Please rank the following in importance to you: least most Guaranteeing your principal 1 2 3 4 5 Life-time income 1 2 3 4 5 Capturing the potential up-side of the market 1 2 3 4 5 Avoiding a market down-turn 1 2 3 4 5 Avoiding the cost of Probate for your heirs 1 2 3 4 5 Reducing your tax es 1 2 3 4 5 Access to your money 1 2 3 4 5 Providing a solution for Long-Term Care 1 2 3 4 5

NEEDS ANALYSIS PROFILE

NOTES