New Client Information Form

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
Last Name
Nickname
Enter the date of birth for the owner of the policy
Male or Female?
Have you ever consumed nicotine products in any form? (Cigarettes, cigars, vaporized liquid, gum, etc.)?
Have you ever consumed cannabis products in any form? (CBD creams or oils, marijuana, etc.)?
Enter your address as it appears on your Driver's License.
Please enter your best contact number.

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

Policy Owner: Past Finances

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

Net Worth: Policy Owner


Assets

Enter total cash holdings. This should include physical cash as well as money held in bank accounts.
Enter total value of current stock and bond holdings.
Enter the current market value for all real estate holdings.
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.
Please briefly describe the sources of any Other Assets. If none, please type “N/A.”

Liabilities

Car loans, credit cards, etc.
Have you filed for bankruptcy within the last seven years?

Current Life Insurance Coverage

(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.
Please list the name(s) of any persons you may wish to insure.
For the proposed insured(s), do you have any health concerns other than tobacco and/or cannabis use? We can discuss possible impact on health rating during our next conversation.
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.
Scroll to Top