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Form 3 – Golden Era Insurance
Retirement Planning
1. How much $ do you have saved for retirement? $
2. Current annual income? $ Income at Retirement? $
3. Assumed interest rate? at Retirement?
4. Assumed inflation rate* Current age?
5. Age when retiring* Yrs. to accumulate?
6. Amount willing to save each month? $
7. How much does your defined benefit pension (if any) provide: $
Long Term Care
1. Can you afford to pay $ 40,000 yr. for health care? Yes No
2. Can your children afford to pay that cost? Yes No
3. If yes, for how many years?
4. Is your family trained to take care of you if you become incapacitated? Yes No
5. If yes, can they afford to quit work to care for you? Yes No
Family Income Protection
1. Does it take both spouses income to pay bills? Yes No
2. What is your monthly minimum living expense? $
3. What is the value provided by at-home parent/caregiver in your household?
4. What conservative investment rate could you expect to earn on your money?
5. How much total life insurance does each spouse have?
$$
Major Purchase/Lease
1. How much will it cost* $
2. How much do you have set aside already? $
3. What is the difference? $
4. Where will the difference come from? $
5. How much can you commit to save* $
6. Would you like some advice on this? Yes No
Savings
1. Do you know how the "RULE OF 72" works? Yes No
2. How much can you comfortably save each month* $
(Rule of 72 works by dividing 72 by the interest rate return on savings The resulting number indicates how many years it takes for money to DOUBLE in value (ex. 72 -:- 8% = 9 yrs.)
Final Expenses
1. Funeral & Cemetery expense* $
2. Medical costs (doctor, hospital, etc.)* $
3. Unpaid loans, bills, debts* $
4. Real Estate Taxes? $
5. Estate Probate (approx. 5-8%) $
5. Total Needed $
Estate Planning
1. Current value of estate? $
2. Current interest rate earned on estate?
3. Current tax bracket?
4. Assumed tax bracket at retirement?
5. Assumed inflation rate?
Education Funding
1. Do you expect your children to attend college? Yes No
2. Do you want to pay for all or part of those costs? Yes No
3. What is the expected annual cost today? $
4. How many years until the money is needed? $
5. How many children? $
6. How much have you currently saved? $
Planning for Parents
1. What concerns you most?
2. Do your parents have a will? Yes No
Do you know where it is? Yes No
Do you have access to it Yes No
Is it current? Yes No
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
Disability Income
1. What is your current income* $
2. What is the amount of income needed to pay bills? $
3. How much income replacement is available from co? $
4. How much would be available from Social Security? $
5. How much is available from Work Comp? $
6. Shortage/Overage $
Income Tax Planning
1. Would you like to reduce your tax bill? Yes No
2. Do you have any interest in an IRA? Yes No
Roth? Yes No
3. What is your current annual income?. $
4. How much do you currently save/invest*. $
5. In what kind of accounts?
Debt-Free Home
1. Do you know the real cost of buying your home? Yes No
2. Have you considered the investment opportunity that could be created with the funds that otherwise go to pay for the mortgage* Yes No
3. Are you familiar with the mortgage acceleration plan? Yes No
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Client Information Worksheet (SRN # 32-7978)

Investment Review
Protection of assets
1. What is greatest fear?
2. What is greatest asset* *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
1. Who do you want the business to go to?
2. Do you have the "piece of paper" that makes this happen? Yes No
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*
Other

1. Specify

2. Ask appropriate questions based Upon concern
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