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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

S CORPORATION

C 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

No

INFORMATION ABOUT EACH KEY EMPLOYEE:

Employee # 1

Employee Name
Position
Annual Salary
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

No

Plan Type

401k

IRA

SEP

SERP

Do you have a buy-sale agreement for partners?

Yes

No

Do you have insurance for key employees?

Yes

No

Financial Planning Objectives

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

Indexed Universal Life

Executive Bonus

Wealth Transfer

Key Employee Insurance

SERP

Talent Retention

Buy-Sell Agreement

Deferred Compensation

Annuities

Tax-Deferred Growth

Define Benefit Plan

Golden Handshake Agreement

Buy Out Agreement

Employee Benefit Program

Owner 1

Name (owner 1)

Phone

Email

Date of Birth

Age

Weight

Height

Marital Status

Single
Married
Divorced
Widowed
Separated
No elements found. Consider changing the search query.
List is empty.

Gender

Male

Female

Smoker?

Yes

No

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 surgeries in the last 10 years? Please list them and when.

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

Do you have a trust?

How much Approximate liquid capital do you have?

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

Stroke

Pacemaker

Stent

Cancer

Diabetes

Units Insulin:

Lupus

COPD

Inhaler

Steroids

Oxygen

Thyroid issues

Kidney Disease

Liver Disease

Dialysis

Anxiety

Depression

Bipolar

High Cholesterol

Parkinson's Disease

Dementia

Alzheimer's Disease

HIV/ AIDS

Units Insulin:
A1C:

Legal Background:

Please check all that apply.

Alcohol/Drug Addictions

Alcohol/Drug Addictions

Resident

Yes

No

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

Yes

No

Any DUI in the past, if so when

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

Yes

No

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

No

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?

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

What is the coverage amount?

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

401k

IRA

ROTH-IRA

STOCKS

BONDS

Mutual Funds

CD

Significant Savings

It is protected from market risk?

Yes

No

Who will be your beneficiary?

IUL Interest

Option 1
No elements found. Consider changing the search query.
List is empty.

What is most important for your long term plan?

Protection

Cash Value

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

I Consent to Receive SMS Notifications, Alerts, and Occasional Marketing Communications from Chicago’s Insurance. Message frequency varies. Message & data rates may apply. Text HELP to 888-411-9334 for assistance. You can reply STOP to unsubscribe at any time. For more information, visit chicagos-insurance.com.

OWNER 2

Full Legal Name *

Phone *

Email *

Date of birth

Age

Weight

Height

Marital Status

Single
Married
Divorced
Widowed
Separated
No elements found. Consider changing the search query.
List is empty.

Gender

Male

Female

Smoker?

Yes

No

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 surgeries in the last 10 years? Please list them and when.

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

Do you have a trust?

How much Approximate liquid capital do you have?

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

Stroke

Pacemaker

Stent

Cancer

Diabetes

Units Insulin:

Lupus

COPD

Inhaler

Steroids

Oxygen

Thyroid issues

Kidney Disease

Liver Disease

Dialysis

Anxiety

Depression

Bipolar

High Cholesterol

Parkinson's Disease

Dementia

Alzheimer's Disease

HIV/ AIDS


A1C:

Legal Background:

Please check all that apply.

Alcohol/Drug Addictions

Resident

Yes

No

Any DUI in the past, if so when

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

Yes

No

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

Yes

No

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

No

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?

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

What is the coverage amount?

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

401k

IRA

ROTH-IRA

STOCKS

BONDS

Mutual Funds

CD

Significant Savings

It is protected from market risk?

Yes

No

Who will be your beneficiary?

IUL Interest

Why are you looking for this plan?

Option 1
No elements found. Consider changing the search query.
List is empty.

What is most important for your long term plan?

Protection

Cash Value

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

I Consent to Receive SMS Notifications, Alerts, and Occasional Marketing Communications from Chicago’s Insurance. Message frequency varies. Message & data rates may apply. Text HELP to 888-411-9334 for assistance. You can reply STOP to unsubscribe at any time. For more information, visit chicagos-insurance.com.

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