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Confidential Information

  • CONTACT INFORMATION

  • Client
  • Address
    City State Zip
  • Daytime Phone
    Evening Phone
  • Email
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  • CUSTOMER INFORMATION

  • Single Married Divorced Widow(er)
  • Name
    DOB
  • Spouse Name
    DOB
  • Name
    DOB
    Add More

  • REFERENCE INFORMATION

  • Employer: Position/Title
    Address
  • City State Zip
    Type of Business
  • Employer: Position/Title
    Address
  • City State Zip
    Type of Business

  • FINANCIAL INFORMATION

  • 10% 28% 33% 35% Other

  • Mr.

  • Mrs.

  • Net annual income from all sources $

  • Primary Residence

  • Value
    Mortgage
  • Payment
    Interest Rate

  • Secondary Residence

  • Value
    Mortgage
  • Payment
    Interest Rate

  • Current Investments

  • Savings/Checking/Money Market/CDs
  • Stock/Bonds/Securities/Brokerage Accounts
  • Investment-Real Estate
  • Mutual Funds
  • Annuities (type/date of issue/company)
  • Collectibles

  • Debt (Credit Cards, Car Loans, %, payment years)

  • Mr., Mrs., Other
    Death Benefit
    Type of Insurance
    Cash Value
    Surrender Value
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  • Long Term Care Insurance (Company, benefit period, inflation, date of issue) & Health Insurance (Company, premium, coverage)

    Add Spouse

  • Current Health Insurances: (Company, premium, coverage)

    Add Spouse

  • INVESTMENT OBJECTIVES

  • Time Horizon: Short (0-5 years)
    Intermediate (6-10 years)
    Long (over 10 years)
    Combination (specify)
  • Goals:
    Preservation of capital [I (We) cannot tolerate loss of principal]
    Income (conservative)
    Income (moderate)
    Income (high yield)
    Capital Appreciation (moderate) Capital Appreciation (aggressive)
    Speculation [I am (We are) willing to risk total loss of principal] *
    Other (please specify)

  • Specific goals or concerns or extraordinary circumstances:

    Foreseeable changes in the information provided herein:

  • INVESTMENT KNOWLEDGE

  • General:
  • Extensive Good Limited None
  • Specific (indicate years of experience):
  • Stocks:
    Bonds:
    Mutual Funds:
    Options:
    Other (specify):

  • ADVISORS

  • Will you independently evaluate each investment and insurance decision?
  • Yes No
  • If no, please provide names of advisors to contact if necessary:

  • Accountant/Tax advisor Name & Phone #

    Legal advisor Name & Phone#

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  • How will you independently evaluate each investment risk?

  • Notes

    Primary Concerns?

    Primary Objectives?

    Primary Goals?

    Health Conditions?

    Prescription Medications?

  • SIGNATURES---AS EVIDENCED BY MY (OUR) SIGNATURE(S) BELOW:

  • I (We) certify that I (we) have read, understand and answered each question or request for information presented on this Agreement, even though I (We) may have received assistance preparing this Agreement as acknowledged above, and that I (we) agree to the terms and conditions herein. Under penalty of perjury, I (We) certify that the New Account Agreement and Suitability Questionnaire information provided above is true, complete, and accurate. I (We) will notify my advisor/agent, in the future of any of the information, needs, goals, or objectives on this agreement change, or of any change in my (our) experience or personal or financial circumstances.
  • Agreement and Suitability Questionnaire

  • Customer Date

  • Joint Account Owner Date

  • Representative Date

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  • Upload Signature

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