New Client Information Form

Who are you working with? *

This will ensure proper routing of your form after you complete it.

This is not an application for life insurance or any other financial product. This form is intended to provide more insight into your personal information and family finances.

If you decide to apply for a product, this information may be used (with your consent) for that purpose as well. Please do not fill this form out unless you have spoken with someone at Perfect Spiral Capital.

It will take some time to complete. Make sure you have at least 30 minutes (it could take more or less time, depending on the complexity of your situation.)

It may be helpful to look ahead and gather the appropriate documentation before beginning to fill the form out.

Policy Owner: Personal Information

In the Policy Owner sections we will deal with the proposed owner of the policy. This can be the same person as the insured, or it can be a different person. Please ask if you have any questions!

Legal Name* Enter your name as it appears on your Driver's License.

First Name *

First Name

Last Name *

Last Name

Nickname

Date of Birth *

Enter the date of birth for the owner of the policy

Sex *

Male or Female?

Nicotine Use *

Have you ever consumed nicotine products in any form? (Cigarettes, cigars, vaporized liquid, gum, etc.)?

Cannabis Use *

Have you ever consumed cannabis products in any form? (CBD creams or oils, marijuana, etc.)?

Address *

Enter your address as it appears on your Driver's License.

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Please enter your best contact number.

Email *

Please enter your preferred email for correspondence related to your life insurance policy.

Policy Owner: Past Finances

Do you currently work for income? *

Do you currently receive income from any source other than work? *

Examples include dividends form stocks, interest payments, Social Security income, withdrawals from retirement accounts, rental property income, etc.)

Do you expect your income to change in the next 12 months? *

Net Worth: Policy Owner

Assets

Cash *

Enter total cash holdings. This should include physical cash as well as money held in bank accounts.

Stocks and Bonds *

Enter total value of current stock and bond holdings.

Real Estate *

Enter the current market value for all real estate holdings.

Other Assets *

Enter any other assets not listed above. Examples could include gold, silver, your ownership stake in a business, the value of vehicles, the value of rare collectables, etc.

Other Asset Sources *

Please briefly describe the sources of any Other Assets. If none, please type “N/A.”

Liabilities

Do you currently have any mortgages? *

Do you currently have any other debts? *

Car loans, credit cards, etc.

Bankruptcy *

Have you filed for bankruptcy within the last seven years?

Current Life Insurance Coverage

Do you currently have life insurance on your own life? *

(From any source. Personally owned, paid through payroll deduction at work, offered by a credit union, etc.)

Policy Owner’s Partner: Personal Information

In the Policy Owner’s Partner sections, we will complete the same information for your fiancée or spouse, if applicable.

Are you married or engaged to be married? *

Do you have any children?

Do you have any grandchildren? *

Who is the proposed insured? *

Please list the name(s) of any persons you may wish to insure.

Underwriting Concerns *

For the proposed insured(s), do you have any underwriting concerns other than tobacco and/or cannabis use? Weight, diabetes, high blood pressure, high cholesterol, hazardous occupations, and many other things may impact the risk class of a particular person. We can discuss possible impact on health rating during our next conversation.

Desired Premium Payment

How much total premium (base policy and Paid-Up Additions) do you want to pay per year, for all policies you want to apply for? This question is not required, but it is extremely helpful for our next conversation. Your answer can (and probably will) change as we continue to talk. Unless otherwise specified, we will split this budget roughly equally among the proposed insured(s) listed above.