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Form 5 – Golden Era Insurance

Customer Information (to be completed by customer)
Date :  
Name : Spouse :
Address :
Home Phone :
Work Phone : Work Phone :
Mobile : Mobile :
E-mail : E-mail :
Employer : Employer :
Perferred method of contact: Home Phone Work Phone Mobile E-mail Best time to call:

Areas of Concern

Please check the boxas of the areas that concern you and then rank these in order of your gratest concern (1) to least concern.
My Retirement Long Term Medical Cost
Maintaining my Family Income Savings and/or Investing Money
Major Purchase/Lease Protecting what I own
Passing my Estate to my family My Children's Future and Education
My Car My Home
Reducing Taxes Eliminate Debt
Taking care of aging parents or disabled adult-children.. Getting sick or hurt
Final Expenses Other (Specify)
Also check and rank the following if you own a business:
Protecting my business
Passing my business to my heirs
If someone at my business dies or gets hurt
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
Data Save
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