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Financial Supplement for Business Insurance

Financial Supplement for Business Insurance Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
MM slash DD slash YYYY
Client Name
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Owner:
Beneficiary:
Assets
Cash and cash equivalents:
Accounts Receivable:
Inventories:
Prepaid expense:
Investments held for trading:
Property, plant and equipment:
Goodwill:
Other intangible fixed assets:
Deferred tax assets:
TOTAL ASSETS:
Net income for last tax fiscal year:
Net income after tax current fiscal year:
Liabilities
Accounts payable:
Current income tax liabilities:
Bank loans:
Other tax liabilities:
Issued debt securities:
Deferred tax liabilities:
Minority interest and equity:
Other liabilities:
TOTAL LIABILITIES:
NET WORTH:
Retained earnings/stockholder equity:
Fair market value of business:
Type of business:
- C Corp
- S Corp
- Partnership
- Sole Proprietorship
- LLC
- LLP
Number of employees:
Year established:
Description of business (mfg., retail, etc.)
Purpose of insurance:
- Key person
- Buy/Sell
- Stock redemption
- Loan
- Deferred Comp
- Other
If other, please describe:
If Buy/Sell, provide names of all partners, percent of business owned, and amount of buy/sell insurance inforce and applied for:
If Key Person, are all other key persons covered by or applying for comparable amounts of insurance?
- Yes
- No
If no, please explain:
If Loan, provide loan amount:
Purpose of loan?
Is firm involved in any judgements, lawsuits, or pending court proceedings?
- Yes
- No
If yes, please explain:
For Insurance Professional Use Only — not intended for use in solicitation of sales to the public. Products and programs offered through Tellus are not approved for use in all states. 07.06.17. Copyright © 2017 Tellus Brokerage Connections

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