Data Input Form for Preliminary Evaluation

Data Input Form for Preliminary Evaluation

INSURANCE GLOBE PARTNERS

BUSINESS INSURANCE PLANNING

Data Input Form for Preliminary Evaluation

A) Company Data

Name of Business______

Address______

PERSON TO CALL AT COMPANY REGARDING THIS FORM: ______

Phone______

E-Mail______

Nature of Business______

Type of Business

Sole Proprietorship___Personal Service Corp.___

Partnership___Limited Liability Company___

“C” Corporation___Other___

“S” Corporation___

Calendar or Fiscal Year______

Business Owner(s)

How many? ______

What % of ownership each has? ______

Regarding the Corporation

Total Number of Shares Outstanding______

Corporate Tax Bracket______

State of Incorporation______

Date of Incorporation______

Are the Owners still active in the business? ______

What is the approximate net worth of the business?______

Would you consider your business a good investment for your family if you were not active in it? YES__ NO__

Do you have a child or other relative now active in the business or one who intends to be active? YES__ NO__

Do your associates have children or other relatives now active in the business or any who intend to be active? YES____ NO____

Does the business have outstanding debts? YES____ NO____

Have you assumed personal liability for any business obligation (note or lease)?

If yes, type of obligation______Amount______

Average annual earnings of business ______

Last three years ______

Last five years ______

Business Attorney ______

Address ______

Phone ______

E-mail ______

Business Accountant ______

Address ______

Phone ______

Email ______

B) Buy-Sell Planning

  • Is there a Buy-Sell Agreement in place? YES____ NO____

C) Key Person/Executive Benefits

  • In addition to yourself, do you have any other Key People in your business? YES__ NO__
  • If YES,
  • How many? ______
  • Does the business own life insurance on these people? YES__ NO__
  • Do you provide Split-Dollar insurance for anyone in your business? YES__ NO__
  • Are there Deferred Compensation plans in place now? YES__ NO__
  • If NO, are there any Key Employees whom you would like to tie to the Company by providing them with retirement income and/or death benefits that they would lose if they left your Company? YES__ NO__
  • Are there Executive Bonus Plans in place? YES__ NO__
  • If NO, would you be interested in a way of providing life insurance for yourself and/or any key people, with the premiums paid for and deducted by the Company?
  • YES__ NO__

D) Qualified Sick Pay Plan

  • Does the Company have a long-term disability plan? YES__ NO__
  • Does the Company have individual disability policies for Key Personnel? YES__ NO__

E) Qualified Retirement Plans

  • Is there one or more qualified retirement plan in place? YES____ NO____
  • If YES, which type(s)?
  • Defined Benefit? YES____ NO____
  • Money Purchase? YES____ NO____
  • Profit Sharing? YES____ NO____
  • 401(k) YES____ NO____
  • SIMPLE IRA? YES____ NO____
  • SEP? YES____ NO____
  • 412(i) YES____ NO____

F) Medical Benefits

  • Do you have a Medical Plan in place? YES____ NO____
  • Do you have a Dental Plan in place? YES____ NO____
  • Do you have a Vision Plan in place? YES____ NO____
  • If NO, to any of the above, would you like to consider implementing one or more of the above plans? YES____ NO___

G) Group Term Life Insurance

  • Does your Company currently have a Group Term Life Insurance Plan in place? Y____ N____
  • If YES
  • Are the costs too high? YES__ NO__
  • Would you like to provide additional coverage for Key Personnel? YES__ NO__
  • If NO, would you like to evaluate implementing a Group Term Life Insurance plan? YES__ NO__

H) Business Overhead Expense Insurance

  • Do you currently have Business Overhead Expense Insurance in Place? YES____ NO____
  • If NO, would you like to evaluate the benefits of such a plan? YES____ NO____

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