Customer Information (to be completed by customer)

Date ____________________

Name ____________________________________________ Spouse's name __________________________________

Address ____________________________________________ City_______________________ ZIP Code __________
Home phone ______________________ Work phone ______________________ Cell phone______________________
Spouse's work phone ________________________________ Spouse's cell phone ______________________________
Email addresses ______________________________________

Areas of Concern
Please check the boxes of the areas that concern you and then rank these in order of your greatest concern (1) to least
concern.
Rank Rank
❑ Retirement funding ____________ ❑ Long Term Care ____________
❑ Family Income ____________ ❑ Savings and Investments ____________
❑ Major Purchase/Lease ____________ ❑ Protection of Assets/Excess Liability ____________
❑ Estate Protection ____________ ❑ Education Funding ____________
❑ Auto Liability Protection ____________ ❑ Home/Tenant Protection ____________
❑ Income Tax Strategies ____________ ❑ Debt Free Home ____________
❑ Aging Parents ____________ ❑ Disability ____________
❑ Final Expenses ____________ ❑ Other (Specify) ____________

Also check and rank the following if you own a business:

❑ Business Liability ____________________________
❑ Business continuation ________________________
❑ Protection of property ________________________
❑ Death or disability of Partner or key person________

Are you currently working with a financial planner or investment advisor?............................❑ Yes ❑ No
Are you satisfied with them? ..................................................................................................❑ Yes ❑ No
Are you satisfied with their results? ........................................................................................❑ Yes ❑ No
Would you like a second opinion?..........................................................................................❑ Yes ❑ No

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 Retirement Funding Estate Protection
1. How much $ do you have saved for retirement? $ ____________ 1. Current value of estate? $____________________
2. Current annual income? $ ______ Income at Retirement? $______ 2. Current interest rate earned on estate? ____________________
3. Assumed interest rate? ________ at Retirement? _____________ 3. Current tax bracket? ____________________
4. Assumed inflation rate? ________ Current age? ______________ 4. Assumed tax bracket at retirement? ____________________
5. Age when retiring?____________ Yrs. to accumulate?__________ 5. Assumed inflation rate? ____________________
6. Amount willing to save each month? $ ______________________

Long Term Care Education Funding

1. Can you afford to pay $ 40,000 yr. for health care? ..❑ Yes ❑ No 1. Do you expect your children to attend college? ❑ Yes ❑ No
2. Can your children afford to pay that cost? ................❑ Yes ❑ No 2. Do you want to pay for all or part of those costs? ❑ Yes ❑ No
3. If yes, for how many years? ______________________________ 3. What is the expected annual cost today? $ ____________
4. Is your family trained to take care of you if you become 4. How many years until the money is needed? ____________
incapacitated? ..........................................................❑ Yes ❑ No 5. How many children? ____________
5. If yes, can they afford to quit work to care for you? ..❑ Yes ❑ No 6. How much have you currently saved? $ ____________
Family Income Protection Aging Parents
1. Does it take both spouses income to pay bills?..........❑ Yes ❑ No 1. What concerns you most? ________________________________
2. What is your monthly minimum living expense? $ ____________ 2. Do your parents have a will? ❑ Yes ❑ No Do you know where
3. What conservative investment rate could you expect to it is? ❑ Yes ❑ No Do you have access to it? ❑ Yes ❑ No
earn on your money? ____________________________________ Is it current? ❑ Yes ❑ No
4. How much total life insurance does each spouse have? 3. Have your parents selected their pension option yet? ❑ Yes ❑ No
$________________________ $________________________ 4. Is your family financially prepared to provide around the
clock care for your parents? ❑ Yes ❑ No

Major Purchase/Lease Disability Income

1. How much will it cost? $ __________________ 1. What is your current income? $ __________
2. How much do you have set aside already? $ __________________ 2. What is the amount of income needed to pay bills? $ __________
3. What is the difference? $ __________________ 3. How much income replacement is available from co? $ __________
4. Where will the difference come from? __________________ 4. How much would be available from Social Security? $ __________
5. How much can you commit to save? $ __________________ 5. How much is available from Work Comp? $ __________
6. Would you like some advice on this? ❑ Yes ❑ No 6. Shortage/Overage $ __________

Savings Income Tax Strategies

1. Do you know how the "RULE OF 72" works? ❑ Yes ❑ No 1. Would you like to reduce your tax bill? ❑ Yes ❑ No
2. How much can you comfortably save each month? $____________ 2. Do you have any interest in an IRA? ❑ Yes ❑ No
Roth? ❑ Yes ❑ No
(Rule of 72 works by dividing 72 by the interest rate return on savings. 3. What is your current annual income? $__________________
The resulting number indicates how many years it takes for money to 4. How much do you currently save/invest? $__________________
DOUBLE in value (ex. 72 -:- 8% = 9 yrs.) 5. In what kind of accounts? __________________
Final Expenses Debt-Free Home
1. Funeral & Cemetery expense? $__________________ 1. Do you know the real cost of buying your home? ....❑ Yes ❑ No
2. Medical costs (doctor, hospital, etc.)? $__________________ 2. Have you considered the investment opportunity
3. Unpaid loans, bills, debts? $__________________ that could be created with the funds that otherwise
4. Real Estate Taxes? $__________________ go to pay for the mortgage? ......................................❑ Yes ❑ No
5. Estate Probate (approx. 5-8%) $__________________ 3. Are you familiar with the mortgage acceleration
6. Total Needed $__________________ plan? ........................................................................❑ Yes ❑ No

Auto Protection of assets Home/Tenant/Property Liability

1. Use Auto Questionnaire
(SRN # 32-7978)
Investment Review (FFS, RRs only)
1. Use CPW (SRN # 31-4996)
1. What is greatest fear? ______________________________ 1. Use Home Questionnaire
2. What is your greatest asset? __________________________ (SRN # 32-7978)
*Agent must determine if prospect is concerned about a thing or their income.
Then use the appropriate set of questions about their concern found elsewhere on this sheet.
Business Continuation Other
1. Who do you want the business to go to? 1. Specify ______________________
2. Ask appropriate questions based
2. Do you have the “piece of paper” that makes this happen? upon concern

3. Will it take money to transfer the business? ❑ Yes ❑ No

4. How much? $ __________
5. Do you have that much now? ❑ Yes ❑ No
6. If no, where will it come from? ____________

“We do not share this information outside the Farmers® Companies or partners.”
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