Customer Focused Questionnaire
General Information
Client’s Name ______
Address______
Email Address______
TelephoneHome: ______Work: ______Cell: ______Fax: ______
Date of Birth___/___/______Social Security # ______
Employer ______Annual Income ______
Spouse’s Name ______
Email Address ______
TelephoneHome: ______Work: ______Cell: ______Fax: ______
Date of Birth___/___/______Social Security # ______
Employer ______Annual Income ______
Total Net Worth ______Income from Investments ______
Number of Children/Dependents ______
- Name ______DOB ____/____/______Educational Savings ______
- Name ______DOB ____/____/______Educational Savings ______
- Name ______DOB ____/____/______Educational Savings ______
- Name ______DOB ____/____/______Educational Savings ______
Number of Grandchildren ______
Do you currently have educational savings for a grandchild or grandchildren? ______
What are your top three financial goals?
- ______
- ______
- ______
Current Holdings______Client______Spouse______Joint______
Primary Residence$ ______$ ______$ ______
Secondary Residence$ ______$ ______$ ______
Other Real Estate$ ______$ ______$ ______
Cash & CD’s$ ______$ ______$ ______
Bonds (Taxable)$ ______$ ______$ ______
Bonds (Muni)$ ______$ ______$ ______
Stocks$ ______$ ______$ ______
Mutual Funds$ ______$ ______$ ______
Annuities (Variable)$ ______$ ______$ ______
Annuities (Fixed)$ ______$ ______$ ______
Qualified Assets:$ ______$ ______$ ______
IRA’s$ ______$ ______$ ______
401K’s$ ______$ ______$ ______
Business Interests$ ______$ ______$ ______
Other (Account Type)
______$ ______$ ______$ ______
______$ ______$ ______$ ______
______$ ______$ ______$ ______
Current Debt
Mortgage$______Rate _____% Term ______Pay-Off ______
Auto(s)$______Rate _____% Term ______Pay-Off ______
Credit Card(s)$______Rate _____% Term ______Pay-Off ______
Home Equity$______Rate _____% Term ______Pay-Off ______
Retirement Calculations
At what age would you like to retire? ______
At what age would your spouse like to retire? ______
Total monthly amount from other income:
Social Security______
Pension ______
Other______
Insurance
1. Long Term Care
Name of Insured ______Company ______
Benefit Amount ______Premium ______Inflation Protection ______
2. Disability
Name of Insured ______Company ______
Monthly Benefit ______Premium ______
3. Life
Name of Insured ______Company ______
Cash Value ______Premium ______Face Amount ______
Estate Planning
WillYes ___ No ___Date Est. ___/___/_____
Power of AttorneyYes ___ No ___Date Est. ___/___/_____
Living TrustYes ___ No ___Date Est. ___/___/_____
Current Trustee ______Successor Trustee ______
Are you a trustee for anyone? Yes ___ No ___
Are you gifting?Yes ___ No ___
If yes, please provide details below:
______
Professional Relationships
CPA ______
Attorney ______
Property and Casualty Agent ______
Health Insurance Provider ______
Current Financial Professional ______
Information Analysis (For Office Use Only)
Comprehensive financial planYes ___ No ___Estate PlanYes ___ No ___
PortfolioYes ___No ___CollCalcYes ___ No ___
Mutual fund hyposYes ___ No ___RetCalcYes ___ No ___
Ins need analysisYes ___ No ___
Chris Hass, Jeff Caufield and Chad Perkins offer securities through Parkland Securities, LLC. Member FINRA/SIPC. Investment advisory representatives offer investment advisory services through Sigma Planning Corporation, a registered investment advisor.
Corvus Capital, LLC is an independently owned company located at 2950 Breckenridge Lane, Suite 6, Louisville, KY 40220.
Phone (502) 451-6363; Fax (502) 451-6364