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Fact Finder Date: _________________________ Personal and Family Information Name Date of Birth Social Security No. E-Mail Address Client _______________ ____/____/______ _______________ _______________ Spouse _______________ ____/____/______ _______________ _______________ Children _______________ ____/____/______ _______________ _______________ ____/____/______ _______________ _______________ _______________ ____/____/______ ____/____/______ _______________ _______________ Residence Information Street Address:___________________________________________________________________________ City, State, Zip:_____________________________________________ q Own? Mortgage Payment: $__________Mortgage Balance: $__________ q Rent? Monthly Rent: $__________ Telephone No:________________ Professional Advisor Information Client’s Will (if applicable): Date ______________ Type _______________________________________ Spouse’s Will: Date ______________ Type _______________________________________ Client’s Trust: Date ______________ Type _______________________________________ Spouse’s Trust: Date ______________ Type _______________________________________ Attorney’s Name: ________________________________ Phone No.: _____________________ Accountant’s Name: ________________________________ Phone No.: _____________________ Employment/Income Information Client Spouse Occupation: __________________________________ __________________________________ Employer: __________________________________ __________________________________ Business Street: __________________________________ __________________________________ Address: __________________________________ __________________________________ City, State, Zip: __________________________________ __________________________________ Phone Number: __________________________________ __________________________________ Fax Number: __________________________________ __________________________________ E-Mail Address: __________________________________ __________________________________ Annual Income: $_________________________________ $_________________________________ Other Income: $_________________________________ $_________________________________ 11963Z North American Company for Life and Health Insurance® | 4350 Westown Parkway, West Des Moines, IA 50266 REV 03-13 Financial Information Assets Savings Investments IRA(s) Real Estate Business Interests Personal Property Other Annuities CDs Mutual Funds Pensions Other Liabilities $__________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ Installment Loans Mortgage(s) Charge Accounts Credit Cards Personal Notes Business Debt Other $__________________ __________________ __________________ __________________ __________________ __________________ __________________ Total Assets $__________________ Total Liabilities $__________________ Monthly Systematic Savings: $____________ Average Monthly Expenses: $________________ Insurance Information Life Insurance Insured Company Policy Number Policy Date Face Amount $ $ $ $ $ Annual Premium Beneficiary $ $ $ $ $ Other Insurance Monthly Disability Benefit: Client $______________ Spouse $______________ Client Spouse Health Insurance: P&C Expiration Dates: ______________ Auto ____________ ______________ Homeowners ____________ ----- Other _______ Planning Priorities Protecting Family’s Lifestyle Protecting Income Providing Education Funds Implementing Savings Plan Planning for Retirement Minimizing Estate Shrinkage Planning for Business Continuation Lower Income Taxes Hedge Inflation Peace of Mind Assure Proper Disposition of Assets Increase Current Income Other: ______________________________ High _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ Medium _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ Low _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ None _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ Please provide accurate and complete information. This Fact Finding Form is intended only as a tool to collect information to assist the agent and client during the sales process. It is not a form required by North American Company. Additional information may be needed prior to the purchase of an insurance product. 11963Z North American Company for Life and Health Insurance® | 4350 Westown Parkway, West Des Moines, IA 50266 REV 03-13
