Annual Life Insurance Policy Review

Annual Life Insurance Policy Review

Specially Prepared For:

Agent Providing Your Beneficiary Review:

Date

Important note

This form is intended to assist policy owners in a review of their arrangements for disposition of their assets upon their death. It is not intended to be estate planning, financial planning, or to offer legal advice. If legal, tax, accounting, or other professional services or advice is needed, the services of a competent professional should be sought.

Instructions to complete form

The purpose of the form is for policy owners and prospective clients to determine if their current beneficiary designations meet their goals. If current and desired plans do not match, the life insurance professional may assist the client in completing any changes to beneficiary designations, if requested to do so. Complete all areas that apply.

Strict Confidentiality

The data contained in this form shall be held in strict confidence and may not be shared with any other person, or organization, including legal, tax, or accounting professionals without the prior authorization of the client.

PART ONE: client information

Full name

Home address

Business address

Occupation

Approximate annual income

Date of birth

Have you ever changed your state of residence? Y N

If yes, when?

Are you divorced? Y N Year of divorce, if applicable

Full name of spouse

Spouse’s date of birth

Children of current marriage

1) Full name

Home address

Phone Birthdate

2) Full name

Home address

Phone Birthdate

3) Full name

Home address

Phone Birthdate

4) Full name

Home address

Phone Birthdate

Children of prior marriage

1) Full name

Home address

Phone Birthdate

2) Full name

Home address

Phone Birthdate

3) Full name

Home address

Phone Birthdate

4) Full name

Home address

Phone Birthdate

Names and ages of grandchildren

Names of client’s parents (if deceased, so indicate)

Name

Home address

Age Phone No.

Names of spouse’s parents (if deceased, so indicate)

Name

Home address

Age Phone No.

Other relatives and individuals who are part of your disposition plan

Advisors

Guardians of minor children

Address

Phone

Executors of your will(s)

Address

Phone

Your attorney

Address

Phone

Your accountant

Address

Phone

Financial advisor

Address

Phone

Other

What would you like to achieve as a result of this beneficiary review?

PART TWO

Please indicate the beneficiaries or disposition of assets in each category below. Ignore any categories which do not apply to you. If no change of beneficiary is desired, leave the “desired” column blank.

Your Beneficiary Designations

Life Insurance

Comments and observations

Qualified Plans and IRAs

Comments and observations

Deposit Accounts

Comments and observations

Other Investments (stocks, mutual funds, real estate, and other investments)

Comments and observations

YOUR WILL

Do you have a will? Y N Does your spouse have a will? Y N

Year will was signed by: Client Spouse

Year will was last updated: Client Spouse

State in which will was executed: Client Spouse

Assets passed by your will – indicate estimated value:

Personal property Real estate

Investments Collections

Other assets – List key assets and estimated value:

Other will provisions:

Names of guardians

Trust created

Other

Do you own a business interest? Y N

Business name and type of business

Estimated value owned by you and your spouse

Buy and sell arrangement in force? Y N

Date of buy and sell Last reviewed on

YOUR TRUST

Do you have a trust? Y N

What is the purpose of your trust?

Year trust was completed Last reviewed on

Name of trust

Name of trustee

List trust beneficiaries

Assets payable to or owned by the trust – List key assets and approximate value:

JOINT TENANCY

List all property owned jointly with others:

Comments and observations

OTHER INFORMATION

This space is for any other information which may be relevant to the beneficiary review.

REFERRALS

Assuming that you are completely satisfied with the service which I have provided, I appreciate you providing me with five referrals who might be interested in a beneficiary review. Thank you in advance.

Name Occupation

Address

Phone

Name Occupation

Address

Phone

Name Occupation

Address

Phone

Name Occupation

Address

Phone

Name Occupation

Address

Phone

NOTES

AUTHORIZATION LETTER INSURANCE/BENEFIT

Date:

To:

Attention: Policyholders Service Department

I have contracted (Agent Name) of (Company Name) address listed above, to analyze my total personal and/or business financial situation and make recommendations based on this analysis.

To enable (Company Name) to properly do this, they need to make inquiries to you concerning my personal financial affairs.

I hereby authorize you to give any information, on a timely basis, to (Company Name) personnel for which they may ask. Your cooperation in this matter will be greatly appreciated.

A PHOTOCOPY of this Authorization shall be as valid as the original and honored as such.

Please attach a current updated in-force ledger and the information requested below.

Date Signed:

Policy Number: Face Value:

Policy Owner:

Primary Beneficiary:

Contingent Beneficiary:

Cash Value: Dividends:

Annual Premium: Riders:

OUTSTANDING LOANS ON LIFE INSURANCE POLICIES: