Financial Growth Questionnaire – Keystar Insurance

Client And Basic Info

Name *

Name

First Name

Last Name

Email *

Enter Email Address

Confirm Email *

Reenter Email Address

Phone *

Date Of Birth *

This is crucial for calculations and product eligibility.

Current Age *

Gender *

Male

Female

Sex assigned at birth.

State Of Residence *

Marital Status *

Single

Married

DivorcedDivorced

Widowed

Age of Spouse *

Employment Status *

Employed

Unemployed

Spouse Employment Status

Employed

Unemployed

Anticipated Retirement Age *

Is Your Mother Alive? *

Yes

Is Your Father Alive? *

Yes

Mother’s Age *

Father’s Age *

Mother’s Age At Death *

Father’s Age At Death *

Current Health Conditions *

Excellent

Standard

Poor

Financial Overview And Funding

Dollar Amount To Be Deposited/Invested *

Plan Funding Source *

Qualified

Unqualified

Will your plan Be Funded With Qualified (e.g. IRA, 401K Rollover) Or Unqualified Money

Plan Funding Type *

Liquid

Non-Liquid

Will your plan be funded with cash readily available (liquid), or must assets be sold (non-liquid)?

Funding From Current Employer Account *

Yes

Like a 401K, 403B.

Approximate Total Liquid Assets *

Checking, Savings, Roth, NQ, Life Cash Values, including any amount proposed for this plan.

Approximate Non Liquid Assets *

Real Estate, Collectibles or Other Assets Excluding Primary Residence

Other Retirements/Investment Assets *

Yes

Do you or your spouse have existing retirement accounts (e.g. other 401Ks, IRAs, TSP, 457, etc)?

Type Of Additional Accounts *

Roth

Traditional

Do You Own Any Other Annuities? *

Yes

Monthly Expenses *

Distribution Goals And Expectations

Primary Goal For This Money *

Accumulation/Growth Only

Required Minimum Distributions

Specific Dollar Amount Per Year

Guaranteed Lifetime Income

Lump Sum Withdrawal At Future Date

Legacy Planning/Wealth Transfer (monies to pass to children, grandkids, charities)

Other

Specific Dollar Amount Per Year *

When Do You Want Distributions To Start? *

Immediately

At 65 Years Old

At Retirement

Specific Expectations/Preferences *

Fixed Rate Only

Can Add More Funds Later

Desire For Access To Funds

Do you have any specific expectations or preferences regarding this money?

Concerns?

Do you have any specific concerns about retirement in general, or about this money, that we should be aware of?

Health And Contingency Planning

Are you concerned about potential future health care needs? *

Yes

Needs such as needing nursing home care or home health care?

Do you have any concerns about critical illnesses, like cancer, heart attack, stroke? *

Yes

Interest in Accelerated Access to Funds? *

Yes

Would you be interested in learning about plan features that could provide accelerated funds in the event of a terminal illness?