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Form 2 – Golden Era Insurance
Personal Information Survey (to be completed by agent)
Personal Questions — F.O.R.E.
Family
Occupation
Recreation
Enjoyment
Insurance Questions
When was your last insurance review?
What changes did you make?
How did you select your current coverage?
Have you updated your Will/Trust in the last 5 years? Yes No
Do you have employee benefits? Yes No
Are you comfortable understanding them? Yes No
How happy are you with your retirement preparations? Yes No
Why?  
Have you and/or your spouse changed jobs, or do you plan to change jobs in the near future? Yes No
What concerns you most about your current insurance plan?
If price then ask: If all companies charged the same price, then what would concern you most?
What would you like your auto/home policy to do for you? 1) 2)
Asset Protection Formula
A. Income: — What is your family’s approximate annual household income?
<$25k $25k - $75k $75k - $125k over 125k
B. Savings: — Do you have any of the following?
Checking account Bonds 401K SEP
Savings account Mutual funds Pension Plan (Self) SIMPLE
CD's IRA Pension Plan (Spouse) Cash Value Life Insurance
Stocks Roth IRA Annuities Other investments/Plans
Are you expecting to receive an inheritance or trust settlement any time soon? Yes No When? Amount $
C. Real Estate:
Which of the following do you own?
Home? Yes No Value Equity
Rental properties? Yes No Value Equity
Commercial properties? Yes No Value Equity
Other? Yes No Value Equity
Description
Real Estate Total Value Equity
D. Total Assets at Risk:
Which of these do you want to surrender if you are sued and have insufficient coverage?
If none, ”Since you don’t want to surrender anything, we need to protect the total value of all of them.”
Total Value: Income + Savings + Real Estate (A + B + C) = $
E. Asset Protection Questions
How much of your assets are in annuities? $
How much of this is in the cash value of life insurance? $
How much life insurance do you own? $
Data Save
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