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

Enter the gross earned income (salary, wages, commissions, and bonuses before taxes and withholding) that you received in the past 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your income.
How did you earn this income? Please list all income sources and a brief description of each.
Enter the gross unearned income (dividends, interest, Social Security income, withdrawals from retirement accounts, rental property income, etc. before taxes and withholding) that you received in the past 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your income.
Please briefly describe any sources of Unearned Income. If none, please type “N/A.”
Do you have any other income sources that were not listed in Earned Income and Unearned Income? Enter the gross amount you received in the last 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your income.
Please briefly describe any sources of Other Income. If none, please type “N/A.

Policy Owner: Future Finances

Enter the gross earned income (salary, wages, commissions, and bonuses before taxes and withholding) that you expect to receive over the next 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your income expectation.
How do you earn this income? Please list all income sources and a brief description of each. If this is the same as you listed in Past Finances, please type “Same.”
Enter the gross unearned income (dividends, interest, Social Security income, withdrawals from retirement accounts, rental property income, etc. before taxes and withholding) that you expect to receive over the next 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your income expectation.
Please briefly describe any sources of Unearned Income. If none, please type “N/A.” If this is the same as you listed in Past Finances, please type “Same.”
Do you have any other income sources that were not listed in Earned Income and Unearned Income? Enter the gross amount you expect to receive in the next 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your income expectation.
Please briefly describe any sources of Other Income. If none, please type “N/A.” If this is the same as you listed in Past Finances, please type “Same.”

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

What is the current balance on your mortgages? If none, please enter “N/A.”
Please enter additional details for each mortgage.

What was the original length of each mortgage?
How many years are left on each?
What is the current value of each property?
What is your monthly payment for each?
What is the current balance of your other outstanding debts? (Car loan, student loan, home improvement loan, etc.)
Please enter additional details for each debt.

What was the original length of each repayment?
How many years are left on each?
What is your monthly payment for each?
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.)
For each policy where you are the insured person, please list:

Life insurance company
Death benefit
Type (Term, Whole, Universal, etc.)
Date of Issue
If none, please type “N/A.”

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.
Partner's 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 partner of 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 partner’s address as it appears on his or her Driver's License.
Please enter your partner’s best contact number.

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

Policy Owner’s Partner: Past Finances

Enter the gross earned income (salary, wages, commissions, and bonuses before taxes and withholding) that your partner received in the past 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your partner’s income.
How did your partner earn this income? Please list all income sources and a brief description of each.
Enter the gross unearned income (dividends, interest, Social Security income, withdrawals from retirement accounts, rental property income, etc. before taxes and withholding) that your partner received in the past 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your partner’s income.
Please briefly describe any sources of Unearned Income. If none, please type “N/A.”
Does your partner have any other income sources that were not listed in Earned Income and Unearned Income? Enter the gross amount your partner received in the last 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your partner’s income.
Please briefly describe any sources of Other Income. If none, please type “N/A.”

Policy Owner’s Partner: Future Finances

Enter the gross earned income (salary, wages, commissions, and bonuses before taxes and withholding) that your partner expects to receive over the next 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your partner’s income expectation.
How does your partner earn this income? Please list all income sources and a brief description of each. If this is the same as you listed in Past Finances, please type “Same.”
Enter the gross unearned income (dividends, interest, Social Security income, withdrawals from retirement accounts, rental property income, etc. before taxes and withholding) that your partner expects to receive over the next 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your partner’s income expectation.
Please briefly describe any sources of Unearned Income. If none, please type “N/A.” If this is the same as you listed in Past Finances, please type “Same.”
Does your partner have any other income sources that were not listed in Earned Income and Unearned Income? Enter the gross amount you expect to receive in the next 12 months. An exact dollar amount is not required, but this should be a reasonable representation of your partner’s income expectation.
Please briefly describe any sources of Other Income. If none, please type “N/A.” If this is the same as you listed in Past Finances, please type “Same.”

Partner’s Current Life Insurance Coverage

(From any source. Personally owned, paid through payroll deduction at work, offered by a credit union, etc.)
For each policy where you are the insured person, please list:

Life insurance company
Death benefit
Type (Term, Whole, Universal, etc.)
Date of Issue
If none, please type “N/A.”
Do you have any children? *
List the full legal name and date of birth for each of your children. If none, enter "N/A.”
For each policy where your child is the insured person, please list:

Life insurance company
Death benefit
Type (Term, Whole, Universal, etc.)
Date of Issue
If none, please type “N/A.”
List the full legal name and date of birth for each of your grandchildren. If none, enter "N/A.”
How much total premium 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.
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