Confidential Personal Planning

Questionnaire
Prepared for: John Doe and Mary Doe

Provided by:
Derek Knight

Table of Contents
Personal Information ...........................2
Children ............................................2
Residence Information.........................2
Professional Advisor Information ...........2
Employment/Income Information ..........2
Financial Information...........................3
Insurance Information .........................3
Planning Priorities ...............................3
Important Information.........................4

Confidential Personal Planning Questionnaire

Personal Information
Name:
Date of Birth:
E-Mail Address:
Height/Weight:
Tobacco Use?:
Hazardous
Occupation?:

Client
______________________
John Doe
4
15
1985
______/______/________
johndoe@yahoo.com
______________________
____ft____inches/____lbs.
6
0
205
__Yes __ No ___________
__Yes __ No ___________
______________________
Police Officer

Spouse
______________________
Mary Doe
8
28
1986
______/______/________
marydoe@yahoo.com
______________________
____ft____inches/____lbs.
5
5
160
__Yes __ No ___________
__Yes __ No ___________
______________________
Nurse

Children
Name:
Date of Birth:

Child 1
_________
Robert Doe
__/__/____
2 28 2009

Child 2
_________
__/__/____

Child 3
_________
__/__/____

Child 4
_________
__/__/____

Residence information
Street Address:
__________________________________________________
345
Fir Street
City, State, Zip:
__________________________________________________
Raceland,
LA, 70394
Home Phone No:
__________________
Cell Phone No: ___________________
9855377456
9852098716
Own?
Mortgage Payment: _________
Mortgage
Balance:
___________
$600
$120,000
Rent?
Monthly Rent: ___________

Professional Advisor Information

Clients Will:
Spouses Will:
Attorneys Name:
Accountants Name:

Date __________
Type __________________________
8/20/2010
Date __________
Type __________________________
8/21/2010
_________________________
Phone No.: _____________
Mark Bergeron
9856910112
_________________________
Phone No.: _____________
Genia Berthelot
9858558665

Employment/Income Information
Occupation:
Employer:
Business Street
Address:
City, State, Zip:
Phone Number:
Fax Number:
E-Mail Address:
Annual Income:
Other Income:

Client
_____________________
Police Officer
_____________________
Lafourche Parish Sheriff's Office
_____________________
878 St. Peter's Street
_____________________
_____________________
Raceland, LA, 70394
_____________________
9855377456
_____________________
9854341122
_____________________
johndoe@yahoo.com
_____________________
$45,000
_____________________
$10,000

Confidential Personal Planning Questionnaire

Spouse
Nurse
______________________
______________________
St. Anne's Hospital
______________________
870 Twin Oaks Drive
______________________
______________________
Raceland, LA, 70394
______________________
9855377456
______________________
9854341122
______________________
marydoe@yahoo.com
______________________
$85,000
______________________
$5,000

Financial Information
Assets
Savings
__________
$150,000
$65,000
Investments
__________
IRA(s)
__________
$70,000
$200,000
Real Estate
__________
Business Interests
__________
$10,000
Personal Property
__________
$35,000
Other
__________
$5,000
$535,000
Total Assets
__________
Current Monthly Systematic Savings:

Liabilities
Installment Loans
Mortgage(s)
Charge Accounts
Credit Cards
Personal Notes
Business Debt
Other
Total Liabilities
$6,000
___________

____________
$110,000
$120,000
____________
____________
$50,000
$15,000
____________
____________
$20,000
____________
$10,000
____________
$8,000
$333,000
____________

Insurance Information
Life Insurance
Policy
Policy
Face
Annual
BeneInsured
Company
Number
Date
Amount
Premium
ficiary
__________
________
_____
________
_______
John Doe
Blue Cross Blue_________
8900555544
Shield
9/10/1999________
$300,000
$8,000
Jane Doe
__________
________
_____
________
_______
Mary Doe
Blue Cross Blue_________
8900555545
Shield
9/10/1999________
$300,000
$8,000
John Doe
__________ ________ _________ _____ ________ ________ _______
__________ ________ _________ _____ ________ ________ _______
Long-Term Care Insurance
Policy
Policy
Daily
Benefit
Annual
Insured
Company
Number
Date
Benefit
Period
Premium
__________ ________ _________ _____ ________ _______
_______
__________ ________ _________ _____ ________ _______
_______
Other Insurance
Monthly Disability Benefit:
Client ___________
Spouse ___________
$0
$0
Critical Illness Insurance Benefit:
Client ___________
Spouse ___________
$0
$0
Health Insurance:
Client Cigna
__________
Spouse ___________
Cigna
P&C Expiration Dates:
Auto ______
Homeowners ______
Other _______
9/2020
9/2025

Planning Priorities
High
Medium
Protecting Familys Lifestyle
_____
_____
Protecting Income
_____
_____
Providing Education Funds
_____
_____
Implementing Savings Plan
_____
_____
Planning for Retirement
_____
_____
Minimizing Estate Shrinkage
_____
_____
Planning for Business Continuation
_____
_____
Other: ______________________
_____
_____
How much do you feel comfortable setting aside on a monthly

Confidential Personal Planning Questionnaire

Low
_____
_____
_____
_____
_____
_____
_____
_____
basis?:

None
_____
_____
_____
_____
_____
_____
_____
_____
$6,000
_________

Important Information
This fact finder serves to help identify your financial needs and priorities and may be
used in developing proposed solutions consistent with your needs and objectives. In
completing this fact finder, you are entrusting our organization with certain personal
and confidential financial data. We recognize that our relationship with you is based on
trust and we hold ourselves to the highest standards in the safekeeping and use of your
confidential information.
The information, general principles and conclusions presented in this report are subject
to local, state and federal laws and regulations, court cases and any revisions of same.
While every care has been taken in the preparation of this report, neither VSA, L.P. nor
The National Underwriter Company is engaged in providing legal, accounting, financial
or other professional services. This report should not be used as a substitute for the
professional advice of an attorney, accountant, or other qualified professional.

VSA, LP

All rights reserved (VSA ff-01 ed. 01-12)

Confidential Personal Planning Questionnaire