FINANCIAL REALITIES. Affecting Your Life and Retirement NEEDS ASSESSMENT CLIENT INFORMATION. Name Birth Date. Spouse Birth Date. Address.

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1 NEEDS ASSESSMENT FINANCIAL REALITIES Affecting Your Life and Retirement CLIENT INFORMATION Name Birth Date Spouse Birth Date Address Children Age City Children Age City Ages of Grandchildren

2 MEDICAL EXPENSES 1. Many people are concerned about their health and the high cost of healthcare. What are you doing to protect yourself? What type of health insurance do you have now? MR. None Medicare only Medicaid Group MedSupp MA MAPD Other Company Name Plan Premium MRS. None Medicare only Medicaid Group MedSupp MA MAPD Other Company Name Plan Premium Drug coverage? Yes No Provider Drug coverage? Yes No Provider Additional Group Benefits? Dental Vision Life Insurance Other 2. So that I can get to know you a little better, tell me about your health in the last three years. Please keep in mind that medical information shown on this form cannot be considered if you are applying for Medical coverage during open enrollment period or other guarantee issue period. 3. What medications are you taking currently? 4. If you could change anything about your present coverage, what would it be? LONG-TERM CARE 5. What type of insurance do you have to cover long-term care? Husband Wife Policy 1 Policy 2 Policy 3 Policy 1 Policy 2 Policy 3 Benefits Covered HHC/NH HHC/NH HHC/NH HHC/NH HHC/NH HHC/NH Company Benefit Period Benefit Amount Elimination Period Inflation Protection Premium 6. If no long-term care insurance: a. Have you ever looked into it? b. Why was it important for you to look into? c. If it was important enough to look into, what prevented you from moving forward? (If price, how much was it?) d. Is that the only reason you did not move forward? 7. Who do you know who has needed long-term care at home or in a nursing facility? 8. How did it affect them emotionally and financially? How did it affect the family? 9. Most people have three main concerns regarding long-term care remaining independent, having choices and protecting their assets. Which of those are your main concerns? Why? 10. What role do you see your children playing when it comes to your long-term care needs? 11. What plans have you made for long-term care?

3 FINAL EXPENSES/SURVIVORS INCOME 12. Do you own life insurance? Face Amount Company Premium Type Primary Beneficiary Cash Value Surrender Value Husband Wife Policy 1 Policy 2 Policy 3 Policy 1 Policy 2 Policy What are your plans for your life insurance? Why do you have it? 14. Do you have a will/trust? When was it last reviewed? 15. What type of plans have you made for your final expenses? 16. If you were financially able to leave a legacy to a person or organization, who would it be? RETIREMENT INCOME/SAVINGS Note: Do not give advice on or discuss investment-based products unless properly licensed. 17. Are you still paying income tax? At this point in your life, is it more important to find ways to increase your income or lower your taxes? 18. Many people are concerned about outliving their money. What concerns do you have? 19. When you retired (retire), did (will) you qualify for Social Security? (monthly amount) A company pension? (monthly amount) Applicant Spouse Applicant Does your pension have survivor benefits for your spouse? 20. How much are your monthly expenses? 21. Are you able to save some money or do you need all of your income to live on? How are your assets currently invested? NON-LIQUID ASSETS Non-Qualified Annuities Non-Qualified Life Insurance Cash Value Qualified IRAs and Annuities Other Qualified Investments (CDs) Real Estate (excluding Primary Residence) Value Primary Residence Who is your investment firm(s)? Name Name Estimated Tax Bracket Spouse LIQUID ASSETS Converts into cash with little or no uncertainty as to value Checking Account #1 Checking Account #2 Savings Account #1 Savings Account #2 Money Markets Mutual Funds (less any fees) CDs (less any fees) Stocks, Bonds or Other Date Account Opened Date Account Opened Household Income Name Phone Address Date

4 CDs (Request copy of statements if available) Bank Name Value Interest Rate Maturity Date Penalty Annuities/IRAs (Request copy of statements if available) Penalty Company Type Value Interest Rate Contract Date Expiration Date 401(k) (Request copy of statements if available) MR. Company Value MRS. Company Value Other (Request copy of statements if available) Type Value Additional Information 22. Why are you setting this money aside? (travel, grandchildren, college, retirement, financial independence) 23. How comfortable are you with the risk involved in your savings? 24. What are your greatest concerns regarding your savings and retirement income? 25. How do you feel about the returns on your savings over the past years? 26. How much of your savings do you believe needs to be totally liquid and accessible for your use? NEIGHBOR REFERRAL LIST I have a list of your neighbors. Do you know any of the people on this list? What can you tell me about them? (Record information on form or Project 15 Activity Manager) May I mention your name as a reference when I approach them? ADDITIONAL INFORMATION AND FOLLOW-UP NOTES (2/10) Internal use only. Manager s Initials

5 COST AND COVERAGE REVIEW Future Needs Assessment Our Cost and Coverage Review Service is a valuable and free service provided as just one of the ways Bankers provides quality customer service. It will provide resources and information to you as to address changes that occur that affect your retirement planning. In the ever changing market, it can be comforting to know, you have insurance professionals proactively looking out for your best interest and prepared to come talk with you about your options! Yes! I would like a periodic Cost and Coverage Review. I permit Bankers Life and Casualty Company or its affiliates to telephone me about my retirement and insurance needs even if I have registered for a state/federal Do-Not-Call list. My permission is valid for three years unless I call and ask to be placed on the company s NO CALL list. Name Signature Date Phone ( ) Best time to call address Please return via Home Office Pouch Mail. Attn: Prospect and Policyholder Marketing Department SDF

6 PERSONAL INFORMATION First Name MEDSUPP COVERAGE Last Name Address City State Zip Phone Birth Date Spouse Name Spouse Birth Date Financial Advisor: Yes No Total Asset Amount (less real estate): Less than $100K $100K to $500K More than $500K Maturing Assets (from most recent statement) LONG-TERM CARE INSURANCE COVERAGE MR. Yes No LTC Comp HC Inflation: Yes No MRS. Yes No LTC Comp HC Inflation: Yes No LIFE INSURANCE COVERAGE Death Benefits: MR. Yes No Term UL Whole Benefit Amount $ Current Cash Value $ Supplemental Data Form REQUIRED Agent Name Agent # BSO # MR. Yes No AARP/United Mutual of Omaha State Farm United World Royal Neighbors of America Blue Cross United American Conseco Bankers United of Omaha Other Company Name Plan: A B C D E F G H I J K L M N MEDICARE ADVANTAGE COVERAGE PART D COVERAGE MR. Yes No UnitedHealthcare Humana Universal American WellPoint WellCare Coventry Other ASSETS MRS. Yes No AARP/United Mutual of Omaha State Farm United World Royal Neighbors of America Blue Cross United American Conseco Bankers United of Omaha Other Company Name Plan: A B C D E F G H I J K L M N MR. Yes No Plan Type: HMO PPO MRS. Yes No Plan Type: HMO PPO UnitedHealthcare Kaiser Humana WellPoint Aetna Coventry Other John Hancock Genworth MetLife Northwestern New York Life Prudential Other UnitedHealthcare Kaiser Humana WellPoint Aetna Coventry Other MRS. Yes No UnitedHealthcare Humana Universal American WellPoint WellCare Coventry Other John Hancock Genworth MetLife Northwestern New York Life Prudential Other Death Benefits: MRS. Yes No Term UL Whole Benefit Amount $ Current Cash Value $