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C O N F I D E N T I A L

CORPORATE DATA REPORTING

FOR ENTERPRISE SOLUTION DESIGN

Make sure to check that all the information is correct.

I. Basic Information of the Company

Company Name: *

Type of Company

LLC

C CORPORATION

S CORPORATION

SOLE PROPRIETOR

Sector of Industry:

Number of Employees:

Years of Foundation:

Location:

II. Financial Information

SALES FROM THE LAST 3 YEARS:

Year 1
Year 2
Year 3

TAXES PAID FROM THE LAST 3 YEARS:

Year 1
Year 2
Year 3

CURRENT YEAR PROJECTED SALES:

PROJECTED TAXES FOR THIS YEAR:

III. BUSINESS STRUCTURE

Number of Partners or Owners:

Percentage of Distribution of shares (for each partner: Name & Percentage).

Book the Value of the Company:

Estimated Market Value:

IV. Key Employee Information

Do you have Key Employees?

Yes

INFORMATION ABOUT EACH KEY EMPLOYEE:

Employee # 1

Employee Name
Position
Option 3
Years in the Company

Employee # 2

Employee Name
Position
Annual Salary
Years in the Company

Employee # 3

Employee Name
Position
Annual Salary
Years in the Company

Employee # 4

Employee Name
Position
Annual Salary
Years in the Company

V. Existing Plans

Do you have an Employee Retirement Plan?

Yes

Plan Type

401k

SEP

IRA

SSERP

Do you have a buy-sale agreement for partners?

Yes

Do you have insurance for key employees?

Yes

Financial Planning Objectives

SELECT THE BUSINESS SOLUTIONS YOU'RE INTERESTED IN) CHECK ALL THE ONES YOU'RE INTERESTED IN):

Indexed Universal Life

Executive Bonus

Key Employee Insurance

Talent Retention

Deferred Compensation

Wealth Transfer

SERP

Buy-Sell Agreement

Annuities

Tax-Deferred Growth

Golden Handshake Agreement

Employee Benefit Program

Define Benefit Plan

Buy Out Agreement

Owner 1

Name (owner 1)

Phone *

Email *

Date of birth

Marital Status

Single
Married
Divorced
Widowed
Separated
No elements found. Consider changing the search query.
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Age

Height

Weight

Smoker

Yes

Gender

Male

Female

Medical Details:

Please note these are not automatic declines, but it helps us get you qualified for the best IUL for you.

Medical Conditions

Heart Attack

Stent

Inhaler

Tyhroid Issues

Dialysis

Bipolar

Dementia

Stroke

Cancer

Lupus

Steroids

Kidney Disease

Anxiety

High Cholesterol

Alzheimer's Disease

Pacemaker

Diabetes

COPD

Oxygen

Liver Disease

Depression

Parkinson's Disease

HIV/ AIDS

Units Insulin:

A1C:

Have you had any surgeries in the last 10 years? Please list them and when.

When was the last time you visited your doctor?

Have you had any transplants? Please list any of them and when.

Have you had any medications prescribed? Even if you didn’t take them please list the name and dosage.

Legal Background:

Please check all that apply.

Resident

Yes

Addiction

Alcohol

Drug

If not Citizen or Resident, Do you have an ITIN?

Yes

Any DUI in the past, if so when

Do you have a permit to work in the United States?

Yes

Place of Birth

Financials

What is your Employment Status

What is your Occupation

Please provide approximate monthly income after deductions

Do you have a mortgage?

Yes

What is the mortgage balance?

What is the approximate housing cost per month?

What type of life insurance do you currently have?

Do you have a death benefit coverage amount in mind?

What is the coverage amount?

Are there any other obligations you would like to make sure are covered in case of your absence?

Do you have anything else in place that acts like life insurance, such as

401k

BONDS

IRA

Mutual Funds

ROTH-IRA

STOCKS

Significant Savings

It is protected from market risk?

Yes

What is most important for your long term plan?

Protection

Cash Value

Who will be your beneficiary?

IUL Interest

Why are you looking for this plan?

Mortgage Protection
IUL
Final Expense
Debt Management
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List is empty.

What is the amount you plan to deposit in this IUL monthly?

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For more information, visit chicagos-insurance.com.

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