Confidential Personal Planning

Questionnaire
Prepared for:

Provided by:

Table of Contents
Personal Information ...........................2
Children ............................................2
Residence Information.........................2
Professional Advisor Information ...........2
Employment/Income Information ..........2
Financial Information...........................3
Insurance Information .........................3
Planning Priorities ...............................3
Important Information.........................4

Confidential Personal Planning Questionnaire

Personal Information
Name:
Date of Birth:
E-Mail Address:
Height/Weight:
Tobacco Use?:
Hazardous
Occupation?:

Client
______________________
______/______/________
______________________
____ft____inches/____lbs.
__Yes __ No ___________
__Yes __ No ___________
______________________

Spouse
______________________
______/______/________
______________________
____ft____inches/____lbs.
__Yes __ No ___________
__Yes __ No ___________
______________________

Children
Name:
Date of Birth:

Child 1
_________
__/__/____

Child 2
_________
__/__/____

Child 3
_________
__/__/____

Child 4
_________
__/__/____

Residence information
Street Address:
__________________________________________________
City, State, Zip:
__________________________________________________
Home Phone No:
__________________ Cell Phone No: ___________________
Own?
Mortgage Payment: _________ Mortgage Balance: ___________
Rent?
Monthly Rent: ___________

Professional Advisor Information

Clients Will:
Spouses Will:
Attorneys Name:
Accountants Name:

Date __________
Type __________________________
Date __________
Type __________________________
_________________________ Phone No.: _____________
_________________________ Phone No.: _____________

Employment/Income Information
Occupation:
Employer:
Business Street
Address:
City, State, Zip:
Phone Number:
Fax Number:
E-Mail Address:
Annual Income:
Other Income:

Client
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________

Confidential Personal Planning Questionnaire

Spouse
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________

Financial Information
Assets
Savings
__________
Investments
__________
IRA(s)
__________
Real Estate
__________
Business Interests
__________
Personal Property
__________
Other
__________
$0
Total Assets
__________
Current Monthly Systematic Savings:

Liabilities
Installment Loans
Mortgage(s)
Charge Accounts
Credit Cards
Personal Notes
Business Debt
Other
Total Liabilities
___________

____________
____________
____________
____________
____________
____________
____________
$0
____________

Insurance Information
Life Insurance
Policy
Policy
Face
Annual
BeneInsured
Company
Number
Date
Amount
Premium
ficiary
__________ ________ _________ _____ ________ ________ _______
__________ ________ _________ _____ ________ ________ _______
__________ ________ _________ _____ ________ ________ _______
__________ ________ _________ _____ ________ ________ _______
Long-Term Care Insurance
Policy
Policy
Daily
Benefit
Annual
Insured
Company
Number
Date
Benefit
Period
Premium
__________ ________ _________ _____ ________ _______
_______
__________ ________ _________ _____ ________ _______
_______
Other Insurance
Monthly Disability Benefit:
Client ___________
Spouse ___________
Critical Illness Insurance Benefit:
Client ___________
Spouse ___________
Health Insurance:
Client __________
Spouse ___________
P&C Expiration Dates:
Auto ______
Homeowners ______
Other _______

Planning Priorities
High
Medium
Protecting Familys Lifestyle
_____
_____
Protecting Income
_____
_____
Providing Education Funds
_____
_____
Implementing Savings Plan
_____
_____
Planning for Retirement
_____
_____
Minimizing Estate Shrinkage
_____
_____
Planning for Business Continuation
_____
_____
Other: ______________________
_____
_____
How much do you feel comfortable setting aside on a monthly

Confidential Personal Planning Questionnaire

Low
_____
_____
_____
_____
_____
_____
_____
_____
basis?:

None
_____
_____
_____
_____
_____
_____
_____
_____
_________

Important Information
This fact finder serves to help identify your financial needs and priorities and may be
used in developing proposed solutions consistent with your needs and objectives. In
completing this fact finder, you are entrusting our organization with certain personal
and confidential financial data. We recognize that our relationship with you is based on
trust and we hold ourselves to the highest standards in the safekeeping and use of your
confidential information.
The information, general principles and conclusions presented in this report are subject
to local, state and federal laws and regulations, court cases and any revisions of same.
While every care has been taken in the preparation of this report, neither VSA, L.P. nor
The National Underwriter Company is engaged in providing legal, accounting, financial
or other professional services. This report should not be used as a substitute for the
professional advice of an attorney, accountant, or other qualified professional.

VSA, LP

All rights reserved (VSA ff-01 ed. 01-12)

Confidential Personal Planning Questionnaire