Comprehensive Fact Finder Prepared for:

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1 Comprehensive Fact Finder Prepared for: Prepared by: Financial Brokerage, Inc. Gary Peterson, CLU, ChFC 2837 s 156 cir Omaha, NE Office: (402) Office: (800) gpeterson@fb-inc.com April 15, 2008 Contents Personal Information Professional Advisors Family Information Assets Income and Capital Needs Insurance Investment Feelings and Preferences Required Documents Employee Benefit Programs Questionnaire Business Information Questionnaire Employee Census Important Information Page Comprehensive Fact Finder for 1

2 Personal Information Name (File No.): Address (Home): Address (Business): Phone (Home): Phone (Cell): Phone (Business): Address: Client: Spouse: Client: Spouse: Client: Spouse: Client: Spouse: Dates of Sessions: Referred By: Professional Advisors Name Address Phone Insurance Agent P&C Agent Attorney Accountant Trust Officer Other Bank Officer Stockbroker Other Comprehensive Fact Finder for 2

3 Family Information Name Date of Birth Citizenship Occupation Health Problems or Special Needs No. and Age of Grandchildren Amount of Support by Client/ Spouse Client s Immediate Family Client Spouse Children* Client s Family (parents, brothers, sisters, etc) Spouse s Family (parents, brothers, sisters, etc) * Indicate if by prior marriage, adopted or stepchild Comprehensive Fact Finder for 3

4 Family Information Client/Spouse Background Data Covered by Social Security?: SOCIAL Client: Yes No Spouse: Yes No SECURITY Have Social Security Benefits been reviewed lately? Yes No MARITAL STATUS RESIDENCE Single Divorced Widowed Married Date married, divorced, widowed: Any former marriages? If yes, give details regarding alimony, child support, etc. Have you lived in another state? If so, where? Give details. Have you or your spouse ever made any gifts? Yes No CUSTODIANSHIPS Who is custodian? Who are the donees? Amounts? Are you or any of your immediate family beneficiaries of a trust? TRUST Yes No BENEFICIARY If so, whom? Include details. GIFTS OR INHERITANCES Are any family members likely to receive any gifts or inheritances? If yes, give details of who, what, when and from whom. EDUCATION & What is educational level? Client: Spouse: MILITARY Any military service? Yes No If yes, from to Who? Do you have a will? Yes No Date of Will: WILLS & MARITAL Does your spouse have a will? Yes No Date of Will: AGREEMENTS Have you named guardians for children? Yes No Who? Do you have a pre- or post-nuptial agreement? Yes No If yes, provide details of the agreement. TRUSTS Have any trusts been created by: Client Spouse If yes, give details of type, who is trustee and beneficiary. Salary: Client $ Other: Client $ ANNUAL INCOME Spouse $ Spouse $ List sources and amounts of other income on the Assets page on this form. Comprehensive Fact Finder for 4

5 ASSETS (Other than Life Insurance and Business Interests) ASSETS CURRENT VALUE COST OR OWNERSHIP % * OTHER BASIS H W C SECURED DEBT DATE ACQUIRED ANNUAL INCOME Primary Residence Secondary Residence Other Real Estate Bonds -- Corporate Bonds -- Municipal Bonds -- Government Stocks -- Listed Stocks -- Unlisted Mutual Funds Bank Accts - - Savings Balance Checking Personal Property Autos and Boats Collections - - Hobby Jewelry Furs - Art Interests in Trusts Mortgages & Notes Other Assets * H = Husband; W = Wife; C = Children; For Jointly Owned Property, Indicate % Under Appropriate Column Comprehensive Fact Finder for 5

6 Income and Capital Needs Income Needs at Death What is your estimate of the monthly income that will be needed for: A. Surviving Spouse and Dependent Children Folowing Client s Death: (1) Adjustment Period (adjustment of standard of living without your income during the transitional period following your death) ( ) years $ (2) Until your youngest child is self-supporting $ (3) To provide life income for surviving spouse after your youngest child is self-supporting $ B. Client and Family: (1) To provide family income in the event of you are seriously disabled $ (2) Lifetime retirement income beginning at age $ Capital Needs at Death Emergency Fund $ Final Expenses $ Mortgage Cancellation Fund $ Notes and Loans Payable $ Estate Taxes/Administrative Costs $ Accrued Taxes (income, real estate, etc.) $ Education Expense $ TOTAL $ Will Basic Health Care and Major Medical Coverage be continued for family after your death? For you: Spouse and Children: After Retirement? Comprehensive Fact Finder for 6

7 Insurance Life Insurance Suggestion: Review policies and most recent policy anniversary premium notices. Insurer Insured Death Benefit Premium Amount and Mode Date of Issue Type Policy Owner of Policy/Premium Payor Policy Number Cash Value and Date Loans Outstanding Are any of the above policies issued other than on a standard or preferred basis? Yes No Disability Income Insurance Insurer Insured Benefit Amount/Duration Premium Amount and Mode Date of Issue Type Policy (Non-Can, G.R., other) Owner of Policy/Premium Payor Policy Number Any Health/Occupation Exclusions Definition of Disability Health Care Insurance Insurer or Service Type Plan Insured Benefits (Rm & Bd., Overall Max) Premium Amount and Mode Date of Issue Type Policy (Hosp., Major Med) Premium Payor Policy Number Any Health/Occupation Exclusions Long-Term Care Insurance Insurer Insured Covered Services/Where Payable Benefit Amount/Duration Premium Amount and Mode Elimination (Waiting) Period Maximum Lifetime Benefit? Guaranteed Renewable? Inflation Adjustment? Date of Issue Premium Payor Policy Number Property & Casualty Insurance Insurer Type Premium Amount and Mode Deductible Renewal Date Policy Number Comprehensive Fact Finder for 7

8 Investment Feelings and Preferences Please indicate which of the following are closest to your investment feelings. I am very conservative. I am willing to give up a potentially higher rate of growth in exchange for knowing my money will be available when needed. I am a moderate risk taker. I would like an investment that is aimed at protecting my money but, at the same time, would offer some growth potential. I believe in a balanced investment portfolio with some of my money guaranteed and some of it in higher risk/return investments. I am very aggressive. I am willing to seek very high growth even with the possibility of high loss. From the following list of investment objectives, indicate your preferences in order (1 through 8) of those most important to you. Liquidity (availability of cash when needed) Current Income Future Income Inflation Protection (protecting purchasing power) Income Tax Deferral/Relief Capital Growth Safety of Principal Other: Please indicate your preference for savings and investment vehicles by rating the following list on a scale of 1 to 5, with 1 being strong preference and 5 slight. (Line out those investments or savings devices you do not prefer at all.) Preference Check If Now Using Check If Unfamiliar Savings Account Cash Value of Life Insurance Government Bonds Corporate Bonds Tax-Exempt Bonds Mutual Funds Variable Annuities Common Stocks Real Estate Tax Shelters Other (specify) Comprehensive Fact Finder for 8

9 Required Documents Data Required Receipt PERSONAL DATA: Your Will Spouse s Wil Trust Agreement(s) Tax Returns (latest plus previous 4 years) Insurance Policies Items Needed PERSONAL DATA Your Will Spouse s Wil Trust Agreement(s) Tax Returns (latest plus previous 4 years) Insurance Policies Initial Client Initial When Returned Company Policy Number Company Policy Number Information Booklet Pension Plan Other Employee Benefits Booklets Employment Contract Deferred Compensation and/or Income Continuation Contract BUSINESS DATA: Buy-Sell Agreement Balance Sheet (latest plus previous 4 years) P&L Statement (latest plus previous 4 years) Insurance Policies Information Booklet Pension Plan Other Employee Benefits Booklets Employment Contract Deferred Compensation and/or Income Continuation Contract BUSINESS DATA: Buy-Sell Agreement Balance Sheet (latest plus previous 4 years) P&L Statement (latest plus previous 4 years) Insurance Policies Company Policy Number Company Policy Number Received by: Date: Date: Comprehensive Fact Finder for 9

10 Employee Benefit Programs Questionnaire Current Employee Benefit Plans (If both spouses work, use a separate sheet for each.) Whenever possible, agreements and supporting documents should be secured for review. A. Life, Health and Disability Insurance Plans Individual Policies Group Insurance Association Plan Insurance Company(s) Other Carriers (past 5 years)? Describe Plan (Eligibility, Benefits, Employee Contributions, Cost, etc.) B. Retirement Plans Keogh Plan IRA TSA Other : Pension Plan Profit-Sharing Plan 401(k) Thrift Plan Date(s) Established? Who Provides Administration? Describe Plan (Eligibility, Benefits, Cost, Employee Contributions, Vesting) C. Selective Benefit Plans Split Dollar Salary Continuation Deferred Sick Pay Plan Compensation Non-Qualified Retirement Travel Accident Other : Describe Plan (Eligibility, Benefits, Cost, Employee Contributions, Vesting) Comprehensive Fact Finder for 10

11 Employee Benefit Programs Questionnaire Client Profile - Employee Benefits (If both spouses work, use a separate sheet for each.) A. What do you like most/least about your present employee benefit program? B. Regarding other employee benefit programs that your firm has either had in effect but discontinued or considered and decided not to adopt, what were the main reasons for such action? C. If your company was to consider adopting a new employee benefit program now or in the future, what would be your thinking and priorities regarding the following? Current Tax Deduction Current Outlay Ultimate Cost Company Control of Funds Ability to Pick and Choose Participants Ease of Administration Flexibility in Deposits Amount of Govt. Reporting/Disclosure Employee Contributions D. Assuming a plan were designed to your satisfaction, how much would you like to allocate to such a program? $ Per Year % of Payroll After Tax Before Tax E. What do you estimate to be your company s current marginal income tax bracket? % F. Other Comments: Comprehensive Fact Finder for 11

12 Business Information Questionnaire I. GENERAL INFORMATION A. NAME OF FIRM Address Telephone Fax Interview With Name Title Extension Name of Secretary/Receptionist Extension B. NATURE OF BUSINESS C. ORGANIZATION Sole Partnership Public Close Corporation Proprietorship Corporation S Corporation P Corporation Tax-Exempt Limited Liability Co. Originally: Date Established: Future: History of Business, etc. Date of Change: Incorporate? Merge? Go Public? Sell to Associates? Give to Children? Date Change Expected: Accounting Year End Method: Cash Accrual Month/Day Number of Employees: Now Last Year 5 Years Ago Hourly Salaried Other D. ADVISORS: Attorney Accountant Banker Investment Advisor Insurance Advisor Other Estimate 2 Years Future Comprehensive Fact Finder for 12

13 II. OWNERSHIP INFORMATION Business Information Questionnaire A. PROPRIETORSHIP/PARTNERSHIP/LIMITED LIABILITY COMPANY Owners Date of Birth Position Health % Ownership Cost Basis for Interest Date Acquired B. CORPORATION CAPITALIZATION Company Totals Common Stock Preferred Stock Shares Authorized Shares Issued # of Voting Shares Last Dividend per Share Date Last Dividend Other Notes Name STOCKHOLDERS (List common and preferred stock separately. Use additional sheet if necessary). Shares Owned * Current Value Cost Basis Date Acquired Position Health * Voting or Nonvoting Comprehensive Fact Finder for 13

14 Business Information Questionnaire III. COMPANY RETENTION OR DISPOSITION A. Is there in existence a Buy-Sell Agreement relative to the disposition of your business interest? Yes No (If No, what do you want to happen to your business? Provide details under Remarks on next page.) B. If Yes, what is the purchase price? $ per share or $ for your entire interest. C. Concerning the Agreement: (1) Type: Mandatory Option First Offer (2) Operative at: Death Disability Retirement (3) Purchaser: Surviving Stockholders or Partners Key Employee Other: Corporation (Redemption) Total Partial (Sec. 303) Partnership (Entity) Other (4) Is the purchase price determined by: Dollar Amount Formula* Book Value (5) Does purchase price realistically reflect value of business? (6) Does purchase price reflect good will? (7) Is Agreement funded? Yes No If yes, indicate below: Life Insurance Amount $ Disability Buy-Out Amount $ Disability Income Amount $ Other (explain) $ (8) Does Agreement restrict lifetime transfer of your stock/business interest? (9) Date Agreement Signed Most Recent Review (10) Does Agreement conform with your present objectives? If not, provide details in Remarks. D. If your business is not currently incorporated, do you plan to incorporate? When? E. Are there any other Agreements concerning your business interest in effect? Please explain * Indicate formula used in determining purchase price. Comprehensive Fact Finder for 14

15 Business Information Questionnaire III. COMPANY RETENTION OR DISPOSITION (continued) F. Does your will contain any provision for the disposition or retention of your business interest? Please explain **G. Does your will direct or authorize your executor to retain and run the business? Please explain **H. Is there a fund to absolve your executor of debts and business losses? Please explain I. What are the names and ages of any relative or child who may enter the business? (1) Do other stockholders or partners agree to such entry? J. If a stockholder or partner should retire, what wil happen to that person s business interest? ** Applicable to sole proprietors and partners. Please attach copy of all agreements and wills mentioned above. REMARKS Comprehensive Fact Finder for 15

16 Business Information Questionnaire IV. FINANCIAL DATA A. BALANCE SHEET What is your estimate of the value of your business as a going concern? $ What is your estimate of the value of your business if liquidated? $ Assets Liabilities Cash $ Accounts Payable $ Accounts Receivable Inventories Real Estate Notes Payable Mortgage Loans Payable Other Goodwill Other Total Liabilities $ Total Assets $ Net Worth (Assets Liabilities) $ B. INCOME Year Net Before Tax Corporate Income Net After Tax Partnership/Proprietorship Net Business Year Income $ $ $ C. BUSINESS INSURANCE IN FORCE Insured Company/ Policy # When Purchased Amount/ Kind Owner/ Beneficiary Purpose Comprehensive Fact Finder for 16

17 Confidential Employee Census Data Name Sex Smoker? (Y or N) Date of Birth Date of Hire Annual Compensation Key Employee? (Y or N) 1. M F Y N / / / / $ Y N 2. M F Y N / / / / $ Y N 3. M F Y N / / / / $ Y N 4. M F Y N / / / / $ Y N 5. M F Y N / / / / $ Y N 6. M F Y N / / / / $ Y N 7. M F Y N / / / / $ Y N 8. M F Y N / / / / $ Y N 9. M F Y N / / / / $ Y N 10. M F Y N / / / / $ Y N 11. M F Y N / / / / $ Y N 12. M F Y N / / / / $ Y N 13. M F Y N / / / / $ Y N 14. M F Y N / / / / $ Y N 15. M F Y N / / / / $ Y N 16. M F Y N / / / / $ Y N 17. M F Y N / / / / $ Y N 18. M F Y N / / / / $ Y N 19. M F Y N / / / / $ Y N 20. M F Y N / / / / $ Y N Comprehensive Fact Finder for 17

18 Important Information The information, general principles and conclusions presented in this report are subject to local, state and federal laws and regulations, court cases and any revisions of same. While every care has been taken in the preparation of this report, neither VSA, L.P. nor The National Underwriter Company is engaged in providing legal, accounting, financial or other professional services. This report should not be used as a substitute for the professional advice of an attorney, accountant, or other qualified professional. This fact finder serves to help identify your financial needs and priorities and may be used in developing proposed solutions consistent with your needs and objectives. In completing this fact finder, you are entrusting our organization with certain personal and confidential financial data. We recognize that our relationship with you is based on trust and we hold ourselves to the highest standards in the safekeeping and use of your confidential information. VSA, LP All rights reserved (VSA ff-14 ed ) Comprehensive Fact Finder for 18