The Hong Kong Confederation of Insurance Brokers

香港保險顧問聯會

(SAMPLE CONFIDENITAL QUESTIONNAIRE)

1. PERSONAL DETAILS

Name Spouse

Date of ANB Date of ANB

Birth Birth

Smoker Yes/No Has Yes/No Smoker Yes/No Has Yes/No

Will Will

Correspondence Tel Fax

Address
Mobile Email

Nationality Nationality

ID Number ID Number

Passport No Passport No

Marital Status Married / Single / Marital Status Married / Single /

Separated / Divorced Separated / Divorced

2. DEPENDANTS

Name Name
1. Date of 2. Date of
Birth Birth
3. Date of 4. Date of
Birth Birth

Education Costs

Nursery:- Starting at age Until Age Annual Cost

Primary:- Starting at age Until Age Annual Cost

Secondary:- Starting at age Until Age Annual Cost

University:- Starting at age Until Age Annual Cost

3. RISK PROFILE

Regular Savings Lump Sum

1
Confidential Questionnaire-1.07
Defensive Defensive
Cautious Cautious
Balanced Balanced
Growth Growth
Aggressive Aggressive

4. EMPLOYMENT

Employer Employer

Occupation Occupation

Address Address

Telephone Fax Telephone Fax

No. No. No. No.

Email Email
Address Address

5. MONTHLY CASHFLOW

INCOME OUTGOINGS
1 Life
st
2 Life
nd
1 Life
st
2nd Life
Salary HK$ HK$ Mortgages HK$ HK$

Investment HK$ HK$ Rent HK$ HK$

Income
Other Income HK$ HK$ Other HK$ HK$
Expenditure

Regular HK$ HK$

Payments

TOTALS HK$ TOTALS HK$

LIABILITIES

Loans/Debts HK$ Taxation/ HK$

Estate Duties

6. FINANCIAL OBJECTIVES

Short Term
Medium Term
Long Term

2
Confidential Questionnaire-1.07
7. ASSETS

Property Property
Address Address
Mortgaged Yes / No Monthly Mortgaged Yes / No Monthly
Cost Cost
Lender Lender
Type Interest only / Capital repayment Type Interest only / Capital repayment
Value Value
Rental Yes / No Amount Rental Yes / No Amount
Income Income

8. INVESTMENTS

DEPOSITS
Bank/Bldg Society Amount Bank/Bldg Society Amount

STOCKS & SHARES

Name No. of Shares Value Name No. of Shares Value

BONDS
Name No. of Shares Value Name No. of Shares Value

9. PROTECTION

LIFE ASSURANCE
Company Sum Premium Term Company Sum Premium Term
Assured Assured

RETIREMENT PROVISION / PENSIONS

Company Premium SRA Value Company Premium SRA Value

3
Confidential Questionnaire-1.07
 CRITICAL ILLNESS COVER
Company Premium Sum Assured Company Premium Sum Assured

INCOME PROTECTION
Company Premium Sum Assured Company Premium Sum Assured

ACCIDENT INSURANCE
Company Premium Sum Assured Company Premium Sum Assured

MEDICAL INSURANCE
Company Premium Sum Assured Company Premium Sum Assured

DENTAL INSURANCE
Company Premium Sum Assured Company Premium Sum Assured

10. OTHER INFORMATION

Bankers Name

Address

Accountants / Solicitors Name

Address

4
Confidential Questionnaire-1.07
11.

Name of Broker

Name of Company

Client Signature(s) Date

5
Confidential Questionnaire-1.07